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Arizona Journal of Pharmacy Summer 2017

BE A PART OF SOMETHING GREAT

The official publication of the Arizona Pharmacy Association brought to you by the Pharmacy Network of Arizona

Keith Boesen, PharmD, CSPI AzPA President 2017-2018

A r i z o n a

P h a r m a c y

A s s o c i a t i o n

Proudly Presents

THE 2017 FALL CONFERENCE The Arizona Pharmacy Association is partnering with the Southwest Diabetes Symposium and the American Society for Medication Therapy Management for a unique educational opportunity! Earn 7.5 hours of CE at this 1 day conference.

Saturday, September 16, 2017 JW Marriott Scottsdale Camelback Inn 5402 East Lincoln Drive Scottsdale, Arizona 85253 To learn more, please visit our website at:

www.azpharmacy.org/event/Fall2017 If you have any questions, please contact us: education@azpharmacy.org (480) 838-3385

The morning sessions are provided complimentarily through our partnership with the Southwestern Diabetes Symposium and therefore the fee covers the lunch and afternoon CE sessions. This conference is jointly Provided by: Arizona Pharmacy Association, St. Josephâ€™s Hospital and Medical Center, MandatoryCE, LLC, and the American Society for Medication Therapy Management

AZPA FALL CONFERENCE AGENDA (Tentative-subject to change) AM sessions are brought to you by the Southwestern Diabetes Symposium in partnership with AzPA* 7:00 am

Registration and Breakfast in Exhibit Area

7:55 am

Welcome and Introduction

8:00 am

Update on the Epidemiology of Type 2 Diabetes Mellitus in the Southwest US Region, Nationwide and Worldwide

8:15 am

9:00 am

9:30 am

Pre-diabetes and Diabetes Prevention: An Update from the CDCâ€™s NDEP Chair

The Overlap of Metabolic Syndrome and Prediabetes: Pathophysiology, Early Identification and Intervention

Practical Tools and Guidelines for Managing Obesity in Patients with Type 2 DM

10:15 am

Break and Refreshments in Exhibit Area

10:45 am

Overview of Current Treatment Options: Comparing Efficacy and Adverse Events

11:15 am

Update on Novel Antidiabetic Agents: Focus on SGLT2s, Incretins, Insulins, and Combination Therapies

12:30 pm

Q&A Panel Discussion

PM sessions are brought to you by the American Society for Medication Therapy Management (ASMTM) in partnership with AzPA 1:00 pm

2:15 pm

5:30 pm

Lunch Medication Therapy Management Case Study Workshops (Rotate through 3 interactive case studies) o Cardiovascular o Diabetes o Immunization Adjourn

Table of Contents Page Number

Journal Section

Board of Directors/ Editorial Board

President’s Message

Association News

Annual Convention Recap

PAPA Message

Legislative Update

Featured Highlights

Continuing Education Allergic Rhinitis Review and Updates in Pharmacologic Management

Pharmacy Comics

Partnering for better health McKesson is proud to sponsor the Arizona Pharmacy Association Supporting hospital and independent retail pharmacies in the delivery of quality patient care. Learn more about how we can help you drive down costs, improve efficiency and identify growth opportunities so that you can focus on what matters most — patient outcomes. Visit us at betterbusinesshealth.com.

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Arizo na Pharmacy Association 2017-2018 Board of Directors Officers Lorri Walmsley

Past President

Jessica DiLeo

President-Elect

Keith Boesen

President

Az-ACCP Chapter

Jeannie Hong, Chair

Managed Care Academy James Montague, Chair

Jaime Von Glahn, Chair-Elect

Aimee (Keller) Itaaehau, Chair-Elect

Patrick Hryshko, Chair-Elect

Brian Seigfried, Chair, MWU Candice Eastman, Chair, U of A TBD, Chair-Elect, MWU Kassie Notbohm, Chair-Elect, U of A

J.R. Gill, Chair

District Directors

Laura Moore, Northeast Jacob Schwarz, Southwest

Secretary

Dean of Colleges

Mitchell R. Emerson, Midwestern University CPG Rick G. Schnellmann, University of Arizona COP

Legal Counsel Roger Morris

Student Pharmacist Academy

Technician Academy

Whitney Rice

John Fezza

Community Pharmacy Academy Health-System Academy

Treasurer

Industry Representative

Stacey Hollen, Chair

Susana Horst, Chair

Lisa Tonrey

Kevin Reger, Chair-Elect

AzPA Staff

Kelly Fine, Chief Executive Officer Cindy Younger, Accounting Deborah Marcum, PAPA Sarah Elenes, Membership Erin Roy, Legislative/Research Liaison Cindy Esquer, Operations Kathy Harty, Continuing Education

Lynette Wasson, Northwest

The interactive digital version of the Arizona Journal of Pharmacy is available for members only online at www.azpharmacy.org/ajp (480) 838-3385 web@azpharmacy.org EDITOR’S NOTE: Any personal opinions expressed in this magazine are not necessarily those held by the Arizona Pharmacy Association. “Arizona Journal of Pharmacy” (ISSN 1949-0941) is published quarterly by the Pharmacy Network of Arizona at: 1845 E. Southern Avenue, Tempe, AZ 85282-5831. Editor

Kelly Fine, R.Ph., FAzPA

Managing Editor Cindy Esquer

Editorial Board Lindsay Davis, Pharm.D. Whitney Rice, Pharm.D. Andrea Burns, Pharm.D. Christi Jen, Pharm.D. Kalani Anderson, C.Ph.T. Nicole Scovis, Pharm.D.

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Creative Coordinator Sarah Elenes

P r e s i d e n t ’s

M e s s a g e

Dear AzPA Members, “The one constant through all the years, Ray, has been baseball. America has rolled by like an army of steamrollers. It’s been erased like a blackboard, rebuilt, and erased again. But baseball has marked the time. This field, this game- it’s a part of our past, Ray. It reminds us all that once was good and it could be again. Oh… people will come Ray; people will most definitely come.” What does that quote have to do with my message as President? Honestly, I have no idea. It just happens to be one of my favorite passages from the movie, Field of Dreams. It often resonates with me and I thought it might get your attention. I bet you are already saying to yourself “What on earth could he say next?” First, I want to thank everyone for the opportunity to serve as President of AzPA. I truly consider this an honor and I do not take this responsibility lightly. It has been a goal of mine for many years while growing up at the AzPA annual convention. I had the opportunity to meet many AzPA Presidents and I thought it was so cool that they were called “President” and even better that they got the giant suite at the annual meeting! During my time as President, I promise to work hard to make AzPA an association that is inclusive to the entire profession through advocacy, education, and communication. To achieve this, I made a “To Do” list for the next year: continue to advance and protect our profession through advocacy, implement improvements from the four focus groups at our annual convention (membership, technology, marketing, and education), update our association bylaws, improve efficiency of the board of directors, and develop a new strategic plan. Wow! Now that I put that in writing, that sounds like bunch of work. Oh boy, I may be in over my head… but then I remember the meetings I attended as a child, walking the exhibit hall, playing a terrible round of golf, rubbing elbows with some amazing members of the association. I would see them working hard but also having fun. It reminds me that I am not alone. AzPA has an outstanding board of directors, an amazing staff, and most importantly, an incredible membership base. I believe we can all work hard, while having some fun, to accomplish the type of advocacy, education, and communication needed for a successful future. An association that can be a legacy to next generation. Wrapping this up, I can’t help but think about that quote from the Field of Dreams and how it might relate to pharmacy. As we continue to improve how we operate as an association, how we advocate for the profession, how we educate our members, and how we communicate to our members, I expect an incredibly bright future for Arizona pharmacy. Maybe we just need to adjust a few of the words, “The one constant through all the years, has been AzPA. Arizona pharmacy has rolled by like an army of steamrollers. It’s been erased like a blackboard, rebuilt, and erased again. But AzPA has marked the time. This association, this profession- it’s a part of our past. It reminds us all that once was good and it could be again.” Yes…I like that…reminds me of my childhood. Let’s have a great year!

Keith Boesen, PharmD, CSPI AzPA President 2017-2018

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A s s o c i a t i o n

N e w s

MISSION STATEMENT

The Arizona Pharmacy Association is committed to serving and representing all pharmacy professionals in all practice settings. AzPA will foster safe and effective medication therapy, promote innovative practice, and empower its members to serve the health care needs of the public. VISION Empowering pharmacy professionals to provide optimal patient care.

Advancing Pharmacy to Improve Healthcare

WELCOME NEW MEMBERS

ASSOCIATES Christie Marshall Joy Ruple NEW PRACTITIONERS Hassan Aden Charity Benson Manal Hammoud PHARMACISTS Charles Aladesanmi Joan Alvarez Alexis Gaggini Phuong Ho Andrew Lester Daniel Lucas Allyssa Nguyen Sunita Patel Nicholas Quaglietta Mark Robertson Donna Thurston RESIDENT Elizabeth Jing Kjersti Rich

RETIRED Robert Da Silva STUDENT Sonya Gadhe Mayra Guzman-Lopez Sam Lee Tim Oâ€™neill Diana Perrett Crystal Rim Krystal Tran TECHNICIAN Rosalie Canaya Jillian Foltz Sarina Patel Tricia Petersen Jami Wiley TECH IN TRAINING Mariana Hernandez NEW MEMBERS: Visit your Member Center to learn how to get more involved with AzPA. Located on www.azpharmacy.org homepage.

CHEERS FOR VOLUNTEERS! We acknowledge the contributions of the volunteers who have made a difference for our organization over the past quarter. Thank you for your continued support of the pharmacy profession. Candice Eastman Seth Anderson Rianne Michael Kassie Notbohm Debra Droopad Krystal (Martin-Ellis) Chandler Somaya Hegazy Isha Shah Jamie Hudgens Brian Seigfried

Kimberly Johnson Derek Tea Thomas Richards Morgan Messmer Diana Perrett Anissa Marzuki Daniel Tucker Jenna Reynolds Ryan Gries Gina Gries Valerie Richards

Jessica DiLeo Jon Glover Heather Leinbach AzPA Board of Directors

Annual Convention Recap

AzPA 2017 Annual Convention Recap Over 400 pharmacists, pharmacy technicians, pharmacy residents, and pharmacy students joined us at the Westin La Paloma Resort & Spa. Thank you to all of our attendees, sponsors, and exhibitors for making the 2017 Annual Convention a tremendous success!

AzPA, APA, AzSHP Past Presidents

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Exhibit Hall

Poster Presentation

Continuing Education

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Thank you, Brooklyn Pizza Company for your donation of gift cards for the

Casino Night Clebration Event!

Casino Night

APF Law on the Links Golf Tournament

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2017 Annual Convention Award Winners Pharmacy Leadership & Incoming President Keith Boesen

Exemplary Patient Care Jennifer Bingham

Outstanding Leadership & Outgoing President Lorri Walmsley Distinguished Young Pharmacist of the Year Stephanie Forbes

Technician of the Year Raquel Arellano Pharmacist of the Year Whitney Rice Bowl of Hygeia Alan Barreuther

Excellence in Innovation Alyssa Peckham

AzPA Fellows Christi Jen Elizabeth Pogge Whitney Rice

Lorri Walmsley

Keith Boesen

Stephanie Forbes

Alyssa Peckham

Jennifer Bingham

Raquel Arellano

Whitney Rice

Alan Barreuther

Elizabeth Pogge & Whitney Rice

PharmPAC Drawdown Winners 1st Place: Jaime Von Glahn $780

4th Place: Imelda Gil $78

2nd Place: Dawn Gerber $390

5th Place: Keith Boesen $78

3rd Place: Jacob Schwarz $390

6th Place: Michael Blaire $78

PharmPAC is a non-partisan voluntary committee that allows AzPA members to pool their financial resources to advance the pharmacy industry by supporting pieces of legislation and state candidates who appreciate the value of our profession.

Poster Contest Winners 1st Place: Alyssa Peckham 2nd Place: Bill Bowman & Betty Lee (tied)

On-Demand Learning. PTCB Exam Prep Course & MPJE Exam Prep Course Everything you need to know. www.azpharmacy.org

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2017 AzPA Exhibitors and Sponsors GOLD ($5,000-$7,499) AbbVie

PLATINUM ($7,500-$10,000) McKesson Corporation

Cardinal Health

Novo Nordisk – Saxenda

GenRx Pharmacy BRONZE ($500-$2,499) Amerisource Bergen

SILVER ($2,500-$4,999) Merck & Co., Inc

Santé Center for Healing

University of Arizona College of Pharmacy

Sanofi

Midwestern University College of Pharmacy EXHIBITORS Alkermes

ICA Health

QS1

Allergan Pharmaceuticals

Janssen Pharmaceutical - CNS Division

Rx relief

American Society for Medication Therapy Management Arizona Pharmacy Foundation AstraZeneca Diabetes Avella Specialty Pharmacy

Janssen Pharmaceuticals Liberty Software Medicare’s Limited Income NET Program Mitchell AutoRx NeilMed Pharmaceuticals, Inc.

RxSystems RxPlus Pharmacies, Inc. Sanofi, Cardiovascular Shire Sigma-Tau Pharmaceutical, Inc.

Boehringer Ingelheim Pharmaceuticals

Northern Arizona Healthcare

Country Financial

Novo Nordisk, Inc.

CSL Behring

PBA Health

Eli Lilly

PEPID

United States Air Force Health Professions

Fry’s Pharmacy

Pfizer Vaccines

Walgreens

GermFree

Pharmacists Mutual Companies

Grifols USA Humana Pharmacy

PharMEDium Services, LLC

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SinfoniaRx Sonoran Prevention Works The Meadows

S A V E

T H E

D A T E

AZPA EVENTS Fall Conference

APF Masquerade Ball

September 16 (Scottsdale)

September 30th (Chandler)

AzPA LEARNING EXPERIENCES Immunization Training Certificate Programs September 23th (Tucson) October 21st (Phoenix)

September 30th (Glendale)

APhA Pharmacy-Based Cardiovascular Disease Risk Management Program - Hosted by AzPA October 28th (Phoenix)

PTCB Exam Prep Course Coming soonth (Tempe)

Pain Management Certificate Program

NEW

November 18th 2018 - Details to come

AzPA Career Center

AzPA Mentor Connection Program

Check out the AzPA Career Center online. Find the best pharmacy-related jobs in the state, or search through resumes of the most highly qualified pharmacists Arizona has to offer. Ask about our employer advertising.

Build relationships, further professional networks, and strengthen continuous professional development! Participation is open to all members.

azpa.webscribble.com

Program runs from October - July, annually! VISIT azpharmacy.org/mentor

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Career Safeguard At Pharmacists Mutual Insurance Company, we protect not only your pharmacy, but you as well. You’re covered no matter where your job takes you, with $1 million per occurrence and as much as $3 million aggregate. In our recent study, we found that 75% of claims were related to wrong drug or wrong dose – even with protocols in place. We know mistakes happen. But you’ve invested too much to become a pharmacist, and now’s the time to help safeguard that investment by purchasing professional liability insurance coverage. Call us today at 800.247.5930 for more information or apply online at phmic.com.

phmic.com Our Mission To help our customers attain peace of mind through specialized insurance products, risk management solutions, and superior personal service.

Not licensed to sell all products in all states.

15 | Summer Journal

G e t

C o n n e c t e d YOU’RE INVITED

Join an AzPA Committee Legislative Committee Co-Chairs : Mark Boesen & Ken Bykowski

Continuing Education Committee Co-Chairs : Nicole Scovis & Lindsay Davis

Membership Committee Co-Chairs : Amy Leung & Kristyn Straw-Wilson

Marketing/Social Media Committee Co-Chairs : Whitney Rice & Kate Murphy

VISIT

www.azpharmacy.org/committees Independent Business Solutions

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Working directly with patients, providers, and pharmacists to ensure the most effective and safest medication therapy possible.

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© 2012 Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO, and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. Lit. No. 1RI9419 (06/2012)

learn more at

www.sinfoniarx.com

cardinalhealth.com

16 | Summer Journal

Pharmacists Assisting Pharmacists of

Arizona (PAPA)

Dangers of Ambien Jim Corrington, Jr. MSW, LCSW PAPA Relapse Prevention Monitoring Program group leader Ambien has been the subject of many discussions and presents as a very problematic drug in several recent cases in my world of addiction treatment, recovery and professional monitoring programs. Frequent stories of “sleep driving” or “driving while in a blackout” are becoming quite common. I’ve recently read a six page police report of a DUI in which the only drug involved was Ambien. The driver was quite impaired and her behavior was bizarre, including her car hitting the officer’s car by accident and just walking away from the officer acting similarly to being in some trancelike state. This person has no memory of the entire incident. She simply took the Ambien “as prescribed” and ended up in jail. Other stories of “sleep eating” and “sleep phone calling” are also heard regularly. I’ve had a professional in recovery whose only drug of choice was Ambien. Prescriptions were being forged to obtain Ambien. I set out to question several local health professionals on what is their experience with Ambien personally and professionally. Here are some of their responses: “It is a very dangerous drug.” “Strong caution is recommended when patients are on Ambien and opioids.” “Amnesia or blackouts are quite common even when taken as prescribed.” “A person should be in bed when it is taken, otherwise odd things can happen.” “A physician or other health professionals prescribing should inquire about the details and history of the sleep problem in context with their entire profile, not just issue a prescription.” One personal example was relayed to me in which the person took the Ambien as prescribed, then proceeded to “take a week’s worth of all my other medications” while in an Ambien blackout. So, in general, Ambien is becoming a very problematic drug for many who are surfacing in the addiction treatment world. Addiction Medicine Physicians will generally steer people who are in recovery from addiction away from all sedative hypnotics, including Ambien. Total abstinence from all mood altering drugs is the goal and Addiction Medicine Physicians should help their patients find alternative ways to enjoy a healthy and normal sleep pattern.

http://www.arizonasocietyofaddictionmedicine.com Arizona Addiction Medicine Physicians can be found on this site.

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L e g i s l a t i v e

U p d a t e

State of Emergency Declared in Arizona Due to the Opioid Overdose Epidemic On June 5, 2017, Arizona Governor Doug Ducey, declared a Public Health State of Emergency due to the opioid epidemic. The declaration directs Arizona Department of Health Services to lead the statewide emergency response. In addition, on June 13, 2017 the Governor issued an Executive Order issuing an Enhanced Surveillance Advisory to track opioid morbidity and mortality. Required reporting, within 24 hours of the items, went into effect on June 15, 2017. REQUIRED REPORTERS

HEALTH CONDITION TO BE REPORTED

REPORTING SYSTEM

Healthcare Professionals licensed under Title 32 and 36 & Administrators of a healthcare institution or correctional facility

• Suspected opioid overdoses • Suspected opioid deaths • Neonatal abstinence syndrome

MEDSIS

Pharmacists

• Naloxone doses dispensed

Prescription Drug Monitoring Program:

http://azhealth.gov/opioid

https://pharmacypmp. az.gov

Training:

https://azpa. learningexpressce.com

Emergency Medical Services/Ambulance agencies & Law enforcement officers

• Suspected opioid overdoses • Suspected opioid deaths • Naloxone doses administered

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AZ-PIERS Training: www.azhealth.gov/ opioidtraining

More information can be found on http://azhealth.gov/opioid As part of the Executive Order, a Statewide Standing Order was put in place for pharmacists in Arizona to be able to dispense naloxone to any patient, caretaker or community member that requests it. All prescriptions should be processed under Cara Christ, MD MS, Director of Arizona Department of Health Services. Please refer to standing order on next page for more information. In order to dispense Naloxone through this standing order, pharmacists must complete a Board of Pharmacy compliant training program. We are happy to announce that AzPA has created a FREE training program that meets these requirements. The training can be found at https://azpa.learningexpressce.com

Whoâ€™s Representing You?

Kelly L. Fine, R.Ph., FAzPA AzPA Chief Executive Officer

Erin Roy AzPA Legislative Liaison

Jessie Armendt Compass Rose Public Affairs AzPA Contract Lobbyist

Mark Boesen, JD, Pharm.D., FAzPA (right) Ken Bykowski, BS Pharm, MSHSA (left) AzPA Legislative Committee Co-Chairs

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F e a t u r e d

H i g h l i g h t s

Analysis of the Clinical and Economic Impact of a Pharmacistled, Behavioral Health, Provider Education Program in a Managed Care Setting Caroline Riedel, PharmD Lauren Pruett, PharmD Michelle Cavner, PharmD The above authors having nothing to disclose. This study did not receive funding or sponsorship in support of the research collected, analyzed and presented. Abstract Purpose: Pharmacists, as part of interdisciplinary teams, have been shown to decrease costs, improve clinical outcomes, and increase provider satisfaction. From the perspective of behavioral health providers, desired pharmacy services have been reported to include controlled substance monitoring, face-to-face communication, and education on new clinical guidelines. Currently, the Clinical Pharmacist Advisor within Mercy Maricopa Integrated Care provides many of these services. However, efforts to measure the impact of this role have not previously been made. The objective of this project was to measure the prescription cost-savings associated with intensified approach of delivering clinical services to providers. The secondary objective was to measure the clinical impact and provider satisfaction associated with the role. Methods: This project was a prospective study that compared prescribers in the intervention group (Partners in Recovery, n=27) to prescribers in the control group (Southwest Network , n=29). Both clinic groups serve patients within the Mercy Maricopa Integrated Care plan who are identified as having a serious mental illness. The intervention group received intensified clinical services (including increased frequency 21 | Summer Journal

of reporting, in-service presentations, and additional reporting) whereas the control group received usual care (annual visits, reporting, and monthly newsletters). The intervention period was October 2016-January 2017. Prescription cost-savings were compared using both year-over-year and three-month pre/post intervention claims data for net prescription cost, average cost per prescription, and average cost per utilizer per month. Additionally, the type and frequency of interventions were tracked and assigned a value for cost-avoidance based on a literature review. Trends in controlled substance prescribing rate, benzodiazepine prescribing rates, and the results of a provider satisfaction survey were also tracked. Results: Year-over-year analysis of pharmacy costs showed a $24.32 increase in cost/script in the intervention group compared to a $31.67 increase in costs in the control group (p=0.0974). Increase in cost per utilizer per month was $93.00 in the intervention group compared to $114.25 in the control group (p=0.7874). Three-month pre/postintervention analysis of pharmacy costs demonstrated an increase in cost/script of $4.00 in the intervention group compared to $3.28 in the control group (p=0.075). Cost per utilizer per month decreased by $14.00 in the intervention group and $32.00 in the control group (p=0.67506). A decreasing trend in controlled substance prescribing was observed in the intervention group (10.55% pre-intervention vs. 10.22% post-intervention). Conclusion: Year-over-year analysis of the Clinical Pharmacy Advisor role suggests that it can lead to a positive clinical impact with the potential to decrease pharmacy costs while increasing the quality of care for members served. Additionally, a decreasing trend in controlled substance prescribing was identified. INTRODUCTION Pharmacists, as part of interdisciplinary teams, have been shown to reduce medication errors and inappropriate prescribing, improve outcomes, reduce costs, and serve as a valuable link in continuity of care.1,2,3 Within the practice of behavioral health, pharmacists have been shown to decrease the prevalence of both polypharmacy and excessive doses.4 Additionally, pharmacist interaction can improve provider satisfaction. Chui, et al. reported that desirable pharmacy services (from a prescriberâ€™s perspective) include controlled substance 22 | Summer Journal

monitoring, training on drug utilization review (DUR) edits, increased face-to-face communication, and education on new clinical guidelines.4,5 The Mercy Maricopa Integrated Care (MMIC) plan is the Regional Behavioral Health Authority (RBHA) for Maricopa County. A RBHA is an organization under contract with Department of Human Services to implement, coordinate, maintain, and monitor the delivery of a unified system of behavioral health services for a geographic area. MMIC is the largest integrated behavioral plan in the Nation, serving over 900,000 members. 20,000 of these individuals are identified as having a serious mental illness (SMI) and are eligible for integrated physical health and behavioral health care. Within the Arizona Health Care Cost Containment System (AHCCCS, the Arizona Medicaid system), SMI eligibility is based upon: adults with an SMI diagnosis and functional impairment caused by the qualifying diagnosis. SMI diagnoses, as defined by AHCCCS, include psychotic disorders, bipolar disorders, depressive disorders, obsessive compulsive disorder, mood disorders, anxiety disorders, post-traumatic stress disorder, dissociative disorders, and personality disorders. The role of the Clinical Pharmacy Advisor is unique to MMIC within Aetna Medicaid. As the liaison between providers and the health plan, responsibilities of the role include: provider reporting (cost/script, number of scripts, generic dispensing rate compare, and controlled substance prescribing rate compared to peer group), top medication lists (by both utilization and cost), annual face-to-face meetings, and monthly prescriber newsletters Despite having a Clinical Pharmacy Advisor within the MMIC plan since Aetna became the plan administrator in 2014, there have been no previous efforts to measure the impact of the role on economic and clinical outcomes. The purpose of this study was to measure the prescription cost-savings (primary outcome) and clinical impact (secondary outcome) associated with intensified clinical services for SMI providers within the clinical pharmacy advisor role. Additionally, provider satisfaction feedback was analyzed to identify the most valued clinical services and to target areas for future quality improvement and expansion of the role. METHODS Data collection was conducted using paid pharmacy claims as reported by CVS Health to Aetna Medicaid for members enrolled in MMIC. Study 23 | Summer Journal

design was approved by the Institutional Review Board (IRB) prior to the start of the intervention period. Intervention Group Prescribers in the Partners in Recovery (PIR) clinic (n = 27) served as the intervention group. Prescribers in this clinic practice out of four different locations within Maricopa country and provide service to SMI members of the MMIC plan. Control Group Prescribers in Southwest Network (SN) clinics (n = 29) were chosen as the control group due to similar practice size and patient characteristics (see results section). Note that the patient makeup of these clinics, with regards to diagnoses, was similar given that they are both SMI clinics. Clinical Pharmacy Advisor Role â€“ Usual Care and Intensified Clinical Services Providers in the control group received usual care. Clinical services provided with usual care are defined as: provider report card (including metrics such as cost/script, generic dispensing rate, and controlled substance dispensing rate), top drug report (identified based on both utilization and cost), monthly newsletter, annual face-to-face visits, and a pharmacist available for drug information questions. The Clinical Pharmacy Advisor within the MMIC plan provided usual care during the intervention period. Providers in the intervention group received intensified clinical services. This included all services provided as part of usual care, as well as: increased frequency of reporting (three quarterly report cards rather than the annual report card), educational in-service presentations (new antipsychotics and/or benzodiazepine tapering), detailed polypharmacy reporting (identifies patients with 5+ psychotropics, 2+ stimulants, 2+ mood stabilizer, 2+ antidepressants from the same class, 2+ antipsychotics, and 2+ benzodiazepines), concomitant opioid and benzodiazepine reporting, a dedicated drug information pharmacist, and attendance at monthly PIR staff meetings. Intensified clinical services were performed by a pharmacy resident in the Clinical Quality department of Aetna Medicaid. The type and frequency of all interventions made were tracked throughout the intervention period.

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Cost-Avoidance A literature review was conducted to assign established cost-savings to the clinical interventions tracked in the intervention group. The values were provided by a study which was conducted in the behavioral health setting. 6 Provider Satisfaction An electronic satisfaction survey was designed to assess satisfaction with current services and to identify areas for potential improvements within the Clinical Pharmacy Advisor role. The survey included Likerttype scales to assess the utility of services (i.e. newsletter, reporting, in-service presentations, etc.) and interventions (i.e. identification of drug-drug interactions, drug-disease interactions, duplication of therapy, inappropriate dosing, etc.) as well as questions to identify services not yet in place that were desirable to prescribers within the plan. A baseline satisfaction survey was sent to prescribers in both the intervention and control groups. A post-intervention survey was sent to prescribers in the intervention group only. All surveys were distributed via email. Study Endpoints The primary endpoint was pharmacy cost-savings as measured by: net pharmacy cost, cost per utilizer per month (PUPM), and cost/script. The intervention and control groups were compared for each metric using both a year-over-year analysis and three-month pre/post analysis. The secondary endpoint was the clinical impact, as measured by: type and frequency of interventions, prescribing trends (controlled substance and benzodiazepine prescribing rates), and provider satisfaction. STATISTICAL ANALYSIS P-values were calculated using a t-test, with two-tails. P-values less than 0.05 were considered to be statistically significant. Prescription Cost-Savings - Year-Over-Year Analysis Year-over-year changes in prescription cost were compared between the intervention and control groups. Changes in pharmacy cost were assessed based on October 2015-January 2016 and October 2016-January 2017 claims data. Metrics for prescription cost-saving were net prescription cost, cost per prescription, and cost PUPM. 25 | Summer Journal

Prescription Cost-Savings - Three-month Pre/Post Analysis Pre- and post- intervention changes in prescription cost were compared between the intervention and control groups. The pre-intervention period was defined as the three-month period before the intervention took place (July-September 2016) and the post-intervention period was the three-month period following completion of the intervention (February-April 2017). Metrics for prescription cost-saving were net prescription cost, cost per prescription, and cost PUPM. Clinical Impact â€“ Benzodiazepine Utilization In the same manner that prescription cost-savings were analyzed based on both year-over-year and pre/post intervention periods, benzodiazepine prescribing rates were compared between the intervention and control groups. The metric was based upon the average percent of claims which were identified as benzodiazepines for the prescriber groups. Additionally, a descriptive analysis of controlled substance prescribing rate for the intervention group was performed. RESULTS Member Characteristics Member characteristics for both clinics during the intervention period (October 2016-January 2017) are as shown in the table below:

Total Utilizers

Average Member Age

% Female

% Male

Intervention Group (PIR)

4,655

57.8

42.2

Control Group (SN)

5,354

52.8

47.2

Table 1 - Member characteristics

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Clinical Interventions – Type, frequency, and cost-avoidance Interventions made as part of the intensified clinical services for the PIR clinic are outlined in the below table. Additionally, the table lists the potential cost-avoidance, as determined based upon literature review.5 The cost-avoidance value for provider report cards is based on reported values for “other therapeutic consult.” The cost-avoidance values for identification of drug-drug interactions and concomitant opioid/ benzodiazepines is based on reported values for “adverse drug even detection” (therefore it represents potential cost-avoidance for cases in which an event was prevented).

Intervention Type

Frequency

Potential CostAvoidance Per Each Intervention ($)

57.67

639

581.08

31.67

581.08

26.97

Provider report cards Drug-drug interaction identification

Educational in-service Concomitant opioid and benzodiazepine identification Formal drug information

Table 2 - Cost-avoidance associated with clinical interventions

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Prescription Cost-Savings - Year-Over-Year Analysis Changes in pharmacy costs were assessed based upon October 2015-January 2016 and October 2016-January 2017 claims data. The table below is a comparison of these year-over-year increases in pharmacy costs. The intervention group had reduced increases in net prescription cost, cost per prescription, and cost PUPM compared to the control group, however the difference did not meet statistical significance for any metric. Intervention Control Group (n=27) Group (n=29)

P-value

$399,552.82

$913,193.32

0.0386

Average increase in cost per prescription

$24.32

$31.67

0.0974

Average increase in cost PUPM

$93.00

$114.25

0.7874

Average increase in monthly net prescription cost

Table 3 - Year-over-year prescription cost-savings Prescription Cost-Savings - Three-month Pre/Post Analysis Table 4 is a comparison of pre-intervention and post-intervention changes in pharmacy costs. Claims data for July-September 2016 was used for the pre-intervention period and claims data for FebruaryApril 2017 was used for the post-intervention period. Converse to the year-over-year analysis, the control group saw less increase (or greater decrease) in pharmacy cost for all pre/post-intervention metrics compared to the intervention group. However, these differences were not statistically significant.

28 | Summer Journal

Average change in monthly net prescription cost Average change in cost per prescription Average increase in cost PUPM

Intervention Group (n=27)

Control Group (n=29)

P-value

$150,744.95

$61,020.48

0.74949

$4.00

$3.28

0.075

-$14.00

-$32.00

0.67506

Table 4 â€“ Pre/post intervention prescription cost-savings

Clinical Impact â€“ Benzodiazepine Utilization Table 5 depicts both year-over-year changes in benzodiazepine utilization (October 2015-January 2016 and October 2016-January 2017 claims data) as well as pre/post-intervention period changes in benzodiazepine utilization between groups (July-September 2016 and February-April 2017 claims data). While the control group saw a statistically significant decrease in utilization based on year-over-year analysis (p<0.05), the control group saw a greater (but non-significant) decrease based on pre/post-intervention analysis. Intervention Group (n=27)

Control Group (n=29)

P-value

Year-over-year change in utilization (%)

-0.2275

-1.015

0.00146

Pre/post-intervention period change in utilization (%)

-0.173

0.00

0.89772

Table 5 - Change in benzodiazepine utilization

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mpact – Controlled Substance Prescribing Rate

Clinical Impact – Controlled Substance Prescribing Rate

ntrolled substance prescribing rate in the PIR clinics over a one year period is depic Controlled substance prescribing rate in the PIR clinics over a one . A decreasing trend in controlled substance prescribing observed. During the year period is depicted in Graph 1. A decreasing trendwas in controlled prescribing was observed. During the eight priorsubstance hs prior to substance the intervention period (as shown in blue) the months controlled to the intervention period (as10.22% shown induring blue) the controlled substance g rate was 10.55% compared to the the intervention period (as shown prescribing rate was 10.55% compared to the 10.22% during the intervention period (as shown in purple).

trolled substance rate trend Graphprescribing 1 – Controlled substance prescribing rate trend

atisfaction Survey

Satisfaction sponse rateProvider was 12.5% (n=7 ofSurvey 56 total prescribers) for the baseline survey and 14.8 Response rate was 12.5% (n=7 of 56 total for the group). baseline t-intervention survey (n=4 of 27 prescribers in prescribers) the intervention survey and 14.8% for the post-intervention survey (n=4 of 27 prescribers in the intervention group).

e usefulness of the services associated with the Clinical Pharmacy Advisor role were The usefulness of the services associated with the Clinical Pharmacy sing a Likert-type scale where 5 corresponded to “extremely useful” and 0 Advisor role were assessed using a Likert-type scale where ded to “not at all useful”. Results indicate that during both the5pre-intervention and corresponded to “extremely useful” and 0 corresponded to “not at all ention surveys, top-rated services included the monthly newsletter. Table 6 describe useful”. Results indicate that during both the pre-intervention and postin more detail. intervention surveys, top-rated services included the monthly newsletter. Table 6 describes the results in more detail.

Service

der report cards hly newsletter g information mitant reporting

Weighted Average (preintervention; 0-5 scale) 3.67 4.57 30 | Summer Journal 4.17 N/A

Weighted Average (post intervention; 0-5 scale) 3.75 4.52 3.67 3.75

Weighted Average (preWeighted Average (postintervention; 0-5 intervention; 0-5 scale) scale)

Service

Provider report cards

3.67

3.75

Monthly newsletter

4.57

4.52

4.17

3.67

N/A

3.75

N/A

3.50

N/A

3.75

Drug information Concomitant reporting In-service presentations Polypharmacy reporting

Table 6 - Usefulness of pharmacy services

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Contact the AzPA Office at 480.207.7869 or papa@azpharmacy.org All calls confidential. Caller remains anonymous. PAPA is a program of the Arizona Pharmacy Foundation

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The usefulness of intervention types was rated in the same manner. All intervention types were rated as equally useful in the post-intervention period. However, during the pre-intervention period drug-drug interactions were identified as the most useful intervention type (table 7).

Intervention type

Weighted Average (pre-intervention; 0-5 scale)

Weighted Average (postintervention; 0-5 scale)

Dru-drug interactions

4.00

3.86

4.00

3.00

4.00

Non-compliance monitoring

3.71

4.00

EKG monitoring recommendations

3.43

4.00

High risk medications

3.71

4.00

Inappropriate dosing

3.71

4.00

3.14

4.00

Non-FDA indication

3.43

4.00

Cost-effective medication recommendation

3.14

4.00

Drug-disease interaction Duplicate therapy

Polypharmacy

Table 7 - Usefulness of pharmacy interventions

Additionally, the survey found that the frequency of face-to-face meetings was rated as â€œadequateâ€? 71.43% of the time in the baseline survey and 100% of the time in the post-intervention survey.

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Prescribers were able to comment on additional services and topics that they would find useful. Responses included the following requests: updates on new clinical research for psychotropic medications, access to an online portal for submission of drug information questions, more clinical information (including treatment resistance, new FDA warnings, concomitant opioids/benzodiazepines, and treatment of addiction/ substance abuse), information on formulary changes, and information on updates to controlled substance monitoring programs. DISCUSSION Tracking the outcomes associated with pharmacy services is essential in efforts to demonstrate value, increase provider satisfaction, and improve quality of care. This study aimed to do just that and represents the first stage in a larger initiative towards tracking the impact of the Clinical Pharmacy Advisor role within Aetna Medicaid. Due to time constraints, the intervention period during which intensified clinical services were performed and tracked was limited to three months. During this time, scheduling conflicts with the intervention provider group arose, which further limited the amount of contact with prescribers. Nonetheless, year-over-year analysis suggests that there may be cost-savings and improved quality of care associated with the clinical pharmacy advisor role. Divergent results for the pre/ post-intervention analysis suggest that increased tracking is essential. The impact of clinical services may have a lingering effect. That is, prescribers oftentimes do not see patients on a frequent basis and identified medication therapy issues may not be resolved or reflected in claims data for several months. As such, continued tracking of both the outcomes for the intervention and control group will be essential to determine whether or not there is an impact beyond the original threemonth post-intervention period. The lack of a statistically significant impact on pharmacy cost-savings may also be partially attributed to the choice of provider groups. The intervention group was selected based upon willingness to participate in the study and the control group was selected due to similarities in the patient population and clinic size. However, the control group was not a true control. The prescriber group for the Southwest Network clinic is historically high-performing, with their own internal educational and reporting programs. Thus, in actuality these prescribers may have received clinical services beyond what those offered through usual care.. 33 | Summer Journal

Another limitation of this study was the challenge associated with assigning cost-avoidance values to clinical services. These values vary widely from study to study and from disease state to disease state. The values selected as an estimate of cost-avoidance in this study were chosen because they were reported in a psychiatric setting and they represent the â€œreduction or elimination of additional expenditures that otherwise may have been incurred if an intervention had not occurred.â€?5 However, the true cost-avoidance is difficult to estimate. Analysis of psychiatric medical claims for patients in the study groups would be helpful in ascertaining non-pharmacy cost-savings associated with the Clinical Pharmacy Advisor role. One hopeful piece of information that this study highlighted was the potential to affect controlled substance prescribing rates and benzodiazepine utilization. Three interventions performed in this study may have contributed to this impact: report cards (prescribers with controlled substance prescribing rates higher than the plan average were notified to raise awareness), concomitant opioid and benzodiazepine reporting (prescribers received a list of patients with concomitant medications and were educated on the risks of coprescribing), and lastly in-service presentations (included discussion of benzodiazepine tapering techniques in an effort to provide necessary tools to decrease benzodiazepine utilization). As with cost-savings metrics, continued tracking will be essential in efforts to identify the longterm impacts of the pharmacy interventions on controlled substance prescribing. Low response rates to the provider satisfaction survey suggest that expanded efforts for feedback should be made. In addition to email delivery of the survey, it is essential to reiterate the importance of prescriber feedback during face-to-face visits. The surveys highlight key areas for improvement as well as educational outreach opportunities that may be targeted as part of continuous quality improvement efforts. Lastly, while this study made efforts to measure the impact of the Clinical Pharmacy Advisor role on both economic and clinical outcomes, it is important to note that the value of the role has broader, intangible benefits. Outreach to prescribers can help to increase engagement between the health plan and prescribers by creating ease of communication and building strong relationships. It is difficult to

34 | Summer Journal

quantify the complete value of the Clinical Pharmacy Advisor role without considering these factors. CONCLUSION Year-over-year analysis of the clinical Pharmacy Advisor role suggests that it has a positive impact that may decrease pharmacy costs while increasing the quality of care for members served. Additionally, a decreasing trend in controlled substance prescribing was identified. Continued tracking is necessary to observe the full impact of the role on both clinical and economic outcomes. A second phase of this study, which will include continued tracking of the original study groups and an expansion of intensified services to physical health providers, is planned. References: 1. Lee, Audrey J, Boro, Maureen S, et al. Clinical and economic outcomes of pharmacist recommendations in a Veterans Affairs medical center. Am J Health-Sysr Pharm. 2002. 59(1): 2070-7. 2. Young, Donna. Pharmaceutical case management helps Iowa Medicaid patients. Am J Health Syst Pharm. 2003;60:414. 3. J Wheeler, Amanda. Crump, K., Lee, M., Li, L., Patel, A., Yang, R., Zhao, J., Jensen, M. Collaborative prescribing: A qualitative exploration of a role for pharmacists in mental health. Research in Social and Administrative Pharmacy. 8 (2012):179â€“192. 4. Hashimoto, Yasuhiko and Tensho, Masami. Effect of pharmacist intervention on physician prescribing in patients with chronic schizophrenia: A descriptive pre/post study. BMC Health Services Research. (2016) 16:150. 5. Chui, M.A., Stone, J.A., Odukoya, O.K., Maxwell, L. Facilitating collaboration between pharmacists and physicians using an iterative interview process. J Am Pharm Assoc. 2014;54:35-41. 6. Campbell, Austin R, Nelson, Leigh A, et al. Analysis of cost avoidance from pharmacy studentsâ€™ clinical interventions at a psychiatric hospital. Am J Pharm Educ. 2011;75(1):8.

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C o n t i n u i n g

E d u c a t i o n

continuing education for pharmacists Volume XXXV, No. 5

Allergic Rhinitis Review and Updates in Pharmacologic Management Cortney Mospan, R.Ph., PharmD, BCACP, BCGP, Assistant Professor of Pharmacy and Elisabeth Schulz, PharmD Candidate, Wingate University School of Pharmacy, Wingate, NC Dr. Mospan and Ms. Schulz have no relevant financial relationships to disclose. Goal. The goal of this lesson is to provide an overview of allergic rhinitis, including symptoms, types and classification, diagnosis, review of guidelines and evidencebased treatment, and discussion of recent changes in pharmacologic therapies. Objectives. At the completion of this activity, the participant will be able to: 1. demonstrate an

understanding of the pathophysiology resulting in allergic rhinitis symptoms and differentiate allergic rhinitis from nonallergic rhinitis; 2. classify allergic rhinitis based on patient symptoms, severity of symptoms, and frequency of symptoms; 3. identify appropriate pharmacologic management of allergic rhinitis based on patient symptoms, updates in evidencebased guidelines, and transition of several intranasal corticosteroids to the over-the-counter

36 | Summer Journal

market; 4. describe adverse effects, safety concerns, and key counseling points associated with pharmacologic treatment options used in allergic rhinitis management; and 5. demonstrate an understanding of nonpharmacological interventions used to help manage allergic rhinitis and the role of the pharmacist. Background Allergic rhinitis is one of the most common disorders in the world, affecting more than 400 million people. In the United States,

approximately 20 percent of adults and 40 percent of children are affected. Prevalence peaks during the second through fourth decades of life and generally diminishes as one ages. Annual direct costs of allergies are estimated to be $3.4 billion. Worldwide, the incidence of respiratory allergic diseases has been increasing for four decades.

patients selfdiagnose and self-manage, making the pharmacist the firstline health care provider for patients suffering from allergic rhinitis.

Allergic rhinitis is an Immunoglobulin E (IgE)-mediated response to allergens. Allergens can result from inhalation (dander or pollen), ingestion (food or penicillin), injection (venom from bee or wasp), or skin Respiratory diseases are contact (latex or plant). now the most common After exposure, the chronic disease among allergen will be identified all adolescents and by the lymph tissue. young adults. Frequently, The lymphocytes then physicians are not produce IgE. Upon reinvolved in the diagnosis exposure, IgE-bound of allergic rhinitis. mast cells interact with Rather, patients self the allergen to release diagnose. inflammatory mediators. Individuals cannot Diagnosis of allergic develop allergic rhinitis rhinitis is usually based without re-exposure. A on clinical symptoms, person will not be with a positive response â€œallergicâ€? to an allergen to oral antihistamines upon his or her first or intranasal exposure. Sensitization corticosteroids. The to the allergen can diagnosis is rarely occur after repeated allergen-specific. exposures, as the Although allergic rhinitis immune system is is a complex disease, primed by the adaptive many patients consider immune response. the disease trivial The immediate reaction because over-theto allergen exposure counter (OTC) includes release of medications are inflammatory mediators amply available. Most (histamine, leukotrienes,

37 | Summer Journal

prostaglandins, and kinins). Next, eosinophils migrate to the nasal mucosa and release additional inflammatory mediators. Late-phase reactions occur in approximately half of allergic rhinitis patients within four to eight hours of exposure, and involve several cytokines that cause the chronic mucosal inflammation and mucus hypersecretion, leading to persistent nasal congestion. The itching sensation associated with allergies is caused by sensory nerve stimulation, and sneezing is caused by a reflex of the efferent vagal pathways. Histamine is responsible for rhinorrhea, itching, sneezing, and nasal obstruction. Nasal obstruction is also caused by kinins, prostaglandin D2, and leukotrienes. The overall effect of these inflammatory mediators results in production of increased nasal secretions, increased vascular permeability, and vasodilation. There is a high prevalence

Table 1 Symptom differentiation for allergic vs. nonallergic rhinitis Allergic Bilateral symptoms, worse upon awakening and at night

Nonallergic Unilateral symptoms likely, constant all day

Sneezing

Frequent, paroxysmal

Little or absent

Rhinorrhea

Watery and anterior

May be watery or thick and/or mucopurulent, posterior

Pruritis of eyes, nose, and/or palate

Frequent

Absent

Conjunctivitis

Frequent

Absent

Anosmia

Rare

May be present

Epistaxis

Rare

Occurs frequently

Key nasal or facial features

“Allergic shiners” Nasal polyps, nasal septal deviation, (periorbital darkening enlarged tonsils and/or adenoids secondary to venous congestion); “Dennie’s lines” (wrinkles beneath the lower eyelids); “Allergic salute” (rub the tip of the nose upward with the palm of the hand); “Allergic crease” (horizontal crease across the nose secondary to the “allergic salute”)

Presentation

Adapted from Krinsky DL, Ferreri SP, Hemstreet BA, et al. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 18th Ed. Washington, DC: American Pharmacists Association; 2015.

results in production of increased nasal secretions, increased vascular asthma permeability, and atopic vasodilation. of and There is a high prevalence dermatitis (eczema) in of asthma and atopic dermatitis (eczema) in patients with allergic patients with allergic rhinitis. There is a possible assorhinitis. ciation of disease severity between asthma and allergic rhinitis. Risk factors for allergic rhinitis include genetic predisposition, higher socioeconomic class, eczema, and a positive reaction to allergy skin tests. In the United States, ragweed and grass pollen are the most common allergens, with ragweed affecting up to 75 percent of Americans who suffer from allergic rhinitis. Commonly, allergic rhinitis is caused by different allergens in the different seasons. In spring,

Risk factors for allergic rhinitis include genetic predisposition, higher socioeconomic class, eczema, and a positive reaction to allergy skin tests. In the United States, ragweed and grass pollen are the most common allergens, with ragweed affecting up to 75

tree pollens are most common; in late spring and summer, grass; and in late summer to fall, ragweed. Grass pollens, such as fescue, Kentucky bluegrass, orchard, redtop, and timothy, often crossreact; whereas, tree pollens such as ash, beech, birch, cedar, hickory, maple, oak, poplar, and sycamore are often distinctive allergens. Pollutants and mold are other common outdoor allergies. Common indoor allergies include dust mites, cockroaches, mold species, cigarette smoke, and animal dander.

percent of Americans who suffer from allergic rhinitis. Commonly, allergic rhinitis is caused by different allergens in the different seasons. In spring, tree pollens are most Identifying Allergic Rhinitis Symptoms common; in lateand spring Classifying Severity and summer, grass; In a community pharmacy setting, a differential diagnosis of allergic and in late summer to fall, ragweed. Grass pollens, such as fescue, Kentucky bluegrass, orchard, redtop, and timothy, often crossreact; 38 | Summer Journal

whereas, tree pollens such as ash, beech, birch, cedar, hickory, maple, oak, poplar, and sycamore are often distinctive allergens. Pollutants and mold are other common outdoor allergies. Common indoor allergies include dust mites, cockroaches, mold species, cigarette smoke, and animal dander.

rhinitis based on patient history, symptoms, and a physical exam is crucial. Typically, tests are not conducted to confirm allergic rhinitis; however, sensitization to an allergen can be confirmed through IgE levels or a positive epicutaneous skin test. Diagnosis can be considered confirmed when 1) there is a history of symptoms to this sensitized allergen, and 2) when there is a wheal and flare reaction to an allergen extract. A wheal is a blanched skin eruption that is surrounded by an area of redness due to histamine release. It is easier to diagnose allergic rhinitis when symptoms occur seasonally and when there is a clear trigger, versus chronic symptoms or multiple triggers. According to guidelines, allergy testing is not currently recommended, unless a patient does not respond to empiric therapy, diagnosis is uncertain, or there is a need to identify the specific cause. Patient history includes environmental factors and exposures, previous medication used to Identifying Allergic manage allergic rhinitis and the Rhinitis Symptoms results, family history, medication list, and medical conditions. Sympand toms and physical exam findings Classifying are listed in Table 1 Severity for differentiation and nonallergic rhiInofaallergic community nitis. Causes of nonallergic rhinitis pharmacy setting, can include infection (rhinosinusitis); work environment (laboratory a differential diagnosis animals, wood dust, mites, latex, of allergic rhinitis based chemicals); medications (NSAIDs, methyldopa, ACE-I, intraocular on patient history, beta blockers, oral contraceptives, symptoms, andfrom a intracocaine use, withdrawal nasal vasoconstrictors); hormones physical exam is crucial. (menstruation, puberty, pregnancy, hypothyroidism, acromegaly); Typically, tests are not tobacco smoke; foods (hot spicy food conducted to confirm and some dyes and preservatives); emotions (stress and sexual arousallergic rhinitis; however, al); atrophic rhinitis, and idiopathic sensitization to an rhinitis. Because as many as one inallergen every four tocan five ambulatory be patients will seek care for allergic confirmed through rhinitis, but exhibit symptoms of nonallergic rhinitis, IgE levels or pharmacists a positive should consider nonallergic rhinitis epicutaneous skin test. as the cause of symptoms as well. Pharmacists should alsobe monitor Diagnosis can for associated comorbidities such as

considered confirmed when 1) there is a history of symptoms to this sensitized allergen, and 2) when there is a wheal and flare reaction to an allergen

extract. A wheal is a blanched skin eruption that is surrounded by an area of redness due to histamine release. It is easier to diagnose allergic rhinitis when symptoms occur seasonally and when there is a clear trigger, versus chronic symptoms or multiple triggers. According to guidelines, allergy testing is not currently recommended, unless a patient does not respond to empiric therapy, diagnosis is uncertain, or there is a need to identify the specific cause. Patient history includes environmental factors and exposures, previous medication used to manage allergic rhinitis and the results, family history, medication list, and medical conditions. Symptoms and physical exam findings are listed in Table 1 for differentiation of allergic and nonallergic rhinitis. Causes of nonallergic rhinitis can include infection (rhinosinusitis); work environment (laboratory animals, wood dust, mites, latex, chemicals); medications (NSAIDs, methyldopa,

ACE-I, intraocular beta blockers, oral contraceptives, cocaine use, withdrawal from intranasal vasoconstrictors); hormones (menstruation, puberty, pregnancy, hypothyroidism, acromegaly); tobacco smoke; foods (hot spicy food and some dyes and preservatives); emotions (stress and sexual arousal); atrophic rhinitis, and idiopathic rhinitis. Because as many as one in every four to five ambulatory patients will seek care for allergic rhinitis, but exhibit symptoms of nonallergic rhinitis, pharmacists should consider nonallergic rhinitis as the cause of symptoms as well. Pharmacists should also monitor for associated comorbidities such as asthma, atopic ermatitis, breathing issues while sleeping, conjunctivitis, rhinosinusitis, and otitis media. These comorbidities can impact selection of optimal drug therapy, and may exclude a patient from self-care. Symptoms that should cue pharmacists into other conditions causing

39 | Summer Journal

nasal symptoms include facial pain, epistaxis (nosebleeds), thick or discolored mucus, symptoms on only one side of the nose, anosmia (loss of smell), or postnasal drip with thick mucus. These patients should be referred to a primary care provider or urgent care setting for further assessment. Allergic rhinitis is classified by the duration and the severity of symptoms. Intermittent allergic rhinitis is classified as symptoms occurring <4 days per week OR <4 weeks. This may also be referred to as seasonal allergic rhinitis. With persistent allergic rhinitis, symptoms occur >4 days per week AND >4 weeks. Mild allergic rhinitis is described as symptoms that do not impair sleep or daily activities (i.e., work, school, sports, and leisure) and are not troublesome. Moderatesevere allergic rhinitis is classified as having one or more of the following: impairment of sleep, impairment of daily activities, or other troublesome

symptoms. asthma, atopic dermatitis, breathing issues while sleeping, conjunctivitis, rhinosinusitis, and otitis Treatment Approach media. These comorbidities can impact selection of Rhinitis optimal drug for Allergic therapy, and may exclude a patient Symptom from self-care. Control Symptoms that shouldexist cue Three guidelines pharmacists into other conditions for allergic rhinitis, with causing nasal symptoms include facial epistaxis (nosebleeds), the pain, most recent being thick or discolored mucus, sympClinical Practice toms on only one side ofGuideline: the nose, anosmia Allergic(loss of smell), or postnasal drip with thick mucus. These Rhinitis, which was to a pripatients should be referred mary care provider or urgent care released by the setting for further assessment. American Academy of Allergic rhinitis is classified by the duration and the severity Otolaryngology of symptoms. Intermittent allergic – Head and Neck rhinitis is classified as symptoms occurring <4 days per week ORin<4 Surgery Foundation weeks. This may also be referred to 2015. This lesson as seasonal allergic rhinitis. With persistent allergic rhinitis, sympwill focus on these toms occur >4 days per week AND guidelines since rhinitis they >4 weeks. Mild allergic is described as symptoms that do are the most recent. not impair sleep or daily activiPharmacists should note ties (i.e., work, school, sports, and leisure) and are guidelines not troublesome. that these Moderate-severe allergic rhinitis is do notaspertain toor more of classified having one the following: impairment of sleep, pediatric patients less impairment of daily activities, or thantroublesome two-years-old other symptoms.as allergic rhinitis presents

Treatment Approach for differently in this patient Allergic Rhinitis Symptom Control population, but they

Three guidelines exist for allergic should betheused in allbeing rhinitis, with most recent Clinical Practice Guideline: Allerother pediatric and adult gic Rhinitis, which was released by patients. the American Academy of Otolaryngology – Head and Neck Surgery Foundation in 2015. This lesson Thefocus Management of since will on these guidelines they are the most recent. PharmaAllergic cists should note that these guidelines do notand pertain pediatric Rhinitis itstoImpact patients less than two-years-old as on Asthma, known as allergic rhinitis presents differently in thisARIA patientguidelines, population, but they the should be used in all other pediatwere released in 2008. ric and adult patients. The Management of The diagnosis andAllergic Rhinitis and its Impact on Asthma,

management of rhinitis: an updated practice parameter was released in 2008 by the Joint Task Force on Practice Parameters for

Table 2 Pharmacologic treatments for allergies OTC Allergy Medications Second-Generation Antihistamines Zyrtec® (cetirizine) Claritin® (loratadine) Allegra® (fexofenadine) Xyzal® (levocetirizine) NasalCrom® (Intranasal cromolyn) Topical and Systemic Decongestants Intranasal Corticosteroids (INCS) Nasacort® Allergy 24HR (triamcinolone acetonide) Rhinocort® (budesonide) Flonase® (fluticasone propionate) Flonase® Sensimist (fluticasone furoate)

Prescription Allergy Medications Second-Generation Antihistamines Clarinex® (desloratadine) Intranasal Antihistamines Patanase® (olopatadine) Astepro®, Astelin® (azelastine) Leukotriene Receptor Antagonists Intranasal Corticosteroids (INCS) Nasonex® (mometasone furoate monohydrate) Omnaris®, Zetonna® (ciclesonide) Qnasl® (beclomethasone dipropionate) Beconase AQ® (beclomethasone dipropionate monohydrate)

Adapted from Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Hudson, OH. Available at: http://online.lexi.com. Accessed February 27, 2017.

known as the ARIA guidelines,

were released 2008. The diagAllergy andin Immunology. nosis and management of rhinitis: These guidelines an updated practice parameter was released in 2008 the Joint Task represent a by joint effort Force on Practice Parameters for between the American Allergy and Immunology. These guidelines represent a joint effort Academy of Allergy, between the American Academy Asthma & Immunology of Allergy, Asthma & Immunology (AAAAI), the American College of (AAAAI), the American Allergy, Asthma, and Immunology College of the Allergy, (ACAAI), and Joint Council of Allergy, Asthma, Asthma, andand Immunology. There are several pharmacologImmunology (ACAAI), ic treatment options available for allergic rhinitis, of whichof are and the Jointmost Council available as OTC medications. TaAllergy, Asthma, and ble 2 provides a listing of prescription and OTC medications used to Immunology. treat allergic rhinitis. None of the pharmacological options available affect progression of allergic rhiniThere are several tis; rather, they simply manage the pharmacologic associated symptoms. Intranasal corticosteroids options (INCS) have become treatment the standard of care with their reavailable for allergic cent transition to OTC availability, and with the release of which the 2015 rhinitis, most of guidelines. The efficacy, safety, and are availableofasINCS OTC cost effectiveness make them the preferred first-line agent. medications. Table INCS provide significantly greater 2relief provides a listing of of nasal blockage, nasal discharge, sneezing, nasal itching, prescription and OTC and post-nasal drip compared to medications used oral antihistamines. INCSto have

treat allergic rhinitis. None of the pharmacological options available affect progression of allergic rhinitis; rather, they

40 | Summer Journal

not been found to provide superior

relief of ocular symptoms; simply manage the an oral or ocular antihistamine may be associated symptoms. preferred for ocular symptoms. Previously, in the ARIA guidelines, Intranasal intranasal corticosteroids where corticosteroids (INCS) only preferred in moderate-severe, persistent allergic rhinitis have become the with step-down therapy recommended standard of were carecontrolled. with once symptoms conjunctivitis symptoms, theirForrecent transition to an oral antihistamine or intraocuOTC availability, and with lar antihistamine/mast-cell stabilizerrelease (Zaditor , Alaway the of the [ketotifen]) 2015 is preferred. Leukotriene-receptor guidelines. Theare not recantagonists (LTRA) ommendedsafety, as first-line therapy efficacy, and in allergic rhinitis. Clinical trials cost of effechave effectiveness shown LTRA to be less tive than other first-line therapies. INCS make them the Their use should be reserved for preferred patients withfirst-line diagnosis of both allergic rhinitis and asthma; howagent. INCS provide ever, they are not recommended significantly greater for first-line treatment in asthma either.of Immunotherapy is only relief nasal blockage, recommended in patients who do nasal discharge, not have an adequate response to standard therapy. sneezing, nasal itching, When developing a pharmacoand post-nasal drip therapy plan for allergic rhinitis, therapy should be directed at the compared to oral symptoms. Sedating antihistaantihistamines. INCS mines should be avoided in favor of the more tolerable second-genhave not been found to eration antihistamines. Although provide treatment superior goals are patient relief of ocular symptoms; an oral or ocular antihistamine may be preferred for ocular symptoms. Previously, in the ARIA ®

guidelines, intranasal corticosteroids where only preferred in moderate-severe, persistent allergic rhinitis with step-down therapy recommended once symptoms were controlled.

therapy should be directed at the symptoms. Sedating antihistamines should be avoided in favor of the more tolerable second-generation antihistamines. Although treatment goals are For conjunctivitis patient Table 2 symptoms, an oral Pharmacologic antihistamine or treatments for allergies intraocular OTC Allergy Medications antihistamine/mast-cell Prescription Allergy stabilizer (Zaditor®, Medications Alaway® [ketotifen]) Second-Generation is preferred. Antihistamines Leukotriene-receptor Second-Generation antagonists (LTRA) are Antihistamines not recommended Zyrtec® (cetirizine) as first-line therapy Clarinex® in allergic rhinitis. Clinical (desloratadine) trials have shown LTRA Claritin® (loratadine) to be less effective Intranasal than other first-line Antihistamines therapies. Their use Allegra® (fexofenadine) should be reserved for Patanase® (olopatadine) patients with diagnosis Xyzal® (levocetirizine) of both allergic rhinitis Astepro®, Astelin® and asthma; however, (azelastine) they are not NasalCrom® (Intranasal recommended cromolyn) Leukotriene for first-line treatment Receptor Antagonists in asthma either. Topical and Systemic Immunotherapy is only Decongestants recommended in Intranasal patients who do not Corticosteroids (INCS) have an adequate Intranasal response to standard Corticosteroids therapy. (INCS) Nasonex® (mometasone furoate When developing a Nasacort® Allergy 24HR pharmacotherapy monohydrate) plan for allergic rhinitis, (triamcinolone

41 | Summer Journal

acetonide) Omnaris®, Zetonna® (ciclesonide) Rhinocort® (budesonide) Qnasl® (beclomethasone dipropionate) Flonase® (fluticasone propionate) Beconase AQ® (beclomethasone Flonase® Sensimist (fluticasone dipropionate monohydrate) furoate) Adapted from Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Hudson, OH. Available at: http://online.lexi.com. Accessed February 27, 2017. specific, the following should be considered: 1) unimpaired sleep, 2) no troublesome symptoms, 3) normal daily activities without limitations (i.e., participation in sports, leisure activities, work attendance), and 4) minimal side effects. Intranasal Corticosteroids (INCS). In recent years, INCS have become available OTC, signaling a major shift in the management of allergic rhinitis since it is primarily a self-care condition. In 2006, the Joint Task Force for the American Academy of Allergy, Asthma and

Immunology and the American College of Allergy, Asthma and Immunology released a white paper regarding the potential switch to OTC status with safety concerns without prescriber oversight. However, pharmacists should feel confident recommending these products to their patients as no significant topical or systemic side effects have been demonstrated in clinical trials. INCS have markedly reduced systemic bioavailability compared to oral and inhaled corticosteroids. With each dose of INCS, approximately 30 percent of the dose is deposited in the nose where it binds with glucocorticoid receptors; the other 70 percent is swallowed and subject to first-pass metabolism in the liver before it becomes systemically available. Side effects of INCS are usually mild, often transient, primarily limited to nasal tissue, and include sneezing; nasal irritation, stinging, or burning; nose bleed; and after taste. A strong correlation has been

found between the nostril that bleeds and the hand used to administer INCS. For example, if the patient administers INCS with their right hand, there is higher risk of bleeding in the right nostril than in the left. Administration technique can increase the incidence of both bleeding and nasal septum perforation; thus, patients should be counseled on appropriate administration technique to minimize side effects. While nasal septum perforation is rare, it is thought to be due to the vasoconstrictive properties of INCS. Reports of perforation are limited, but when reported, perforation generally occurs during the first 12 months of use. Occasional nasal septum perforation has been reported; however, it is believed that this is due to trauma from improper use of the INCS or other factors such as cocaine or decongestant abuse. There are also risks for atrophy of the nasal

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mucosa and changes in nasal epithelial cells, but studies from 12 months to five years do not show adverse outcomes as a result of these changes. Systemic side effects such as hypothalamicpituitary-adrenal (HPA) axis suppression, growth stunting, and other prominent oral corticosteroid side effects are not consistently shown in the literature and are not thought to be clinically significant. INCS should be of minimal concern in patients with diabetes compared to oral corticosteroids. Oral corticosteroids can cause cortisol-induced insulin resistance with long-term use and impair glucose tolerance. After three months of use, triamcinolone acetonide was found to have no impact on A1c or fasting blood glucose. Proper administration technique will minimize the risk of systemic side effects. Growth stunting in children using INCS was reported for beclomethasone dipropionate in many population studies. It is generally thought that

this may be as little as 1 cm in height, which is not clinically significant. However, additional studies are needed. Although INCS have been proven safe, they should be avoided in patients with existing nasal conditions, such as nasal polyps or any olfactory disorders. As previously mentioned, INCS are the most effective treatment option for allergic rhinitis, and current guidelines recommend these for first-line therapy. INCS provide therapeutic effect by interrupting the “allergic cascade,” have potent anti-inflammatory effects, and prevent the release of histamine. Some studies have shown INCS provide better overall symptom relief; however, other studies have shown oral antihistamines are more effective for ocular symptoms. INCS also improve quality of life and sleep for patients. Ciclesonide, fluticasone furoate, fluticasone propionate and mometasone furoate may be preferred INCS as they have lower systemic bioavailability.

These INCS are second-generation and have favorable pharmacokinetics that decrease their systemic bioavailability further. These may be ideal agents to recommend to patients, primarily those available OTC. While INCS are the most effective treatment for allergic rhinitis, they have a delayed onset of action of 12 to 24 hours, a peak effect that takes several days to occur, and require daily or continuous use for optimal therapeutic benefit. Typically, it takes two weeks of use to start to see benefit and improvement in allergic rhinitis symptoms.

receptor. Histamine is directly responsible for many symptoms of allergic rhinitis including mucus secretion, vascular permeability, and sensory nerve stimulation. Oral antihistamines provide relief of many nasal symptoms associated with allergic rhinitis; however, their relief is not as effective as INCS. Oral antihistamines generally have no effect on nasal congestion, and a decongestant may also be required. A combination of a second-generation antihistamine with an oral decongestant has been shown to provide significantly greater symptom Oral Antihistamines. control in patients with Firstgeneration ragweed allergy. This “sedating” antihistamines may be a suitable should not be used in treatment option for the management of seasonal allergic rhinitis allergic rhinitis. with occasional Patients should decongestant use, but be managed on a the cardiovascular second-generation risks of decongestants “nonsedating” do not warrant daily use. antihistamine as they INCS have also been have a more favorable shown to provide nasal side effect profile and blockage and discharge are just as effective at relief, and may be a managing symptoms. suitable alternative for Oral antihistamines long-term congestion work by blocking the management. effects of histamine at Oral antihistamines are the histamine-1 (H1) generally less effective

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than INCS, but still provide symptom relief. Compared to INCS, oral antihistamines provide greater relief of ocular symptoms and potentially greater relief of nasal itching, but not other nasal symptoms such as congestion.

likely with cetirizine compared to other second-generation antihistamines.

Few head-to-head studies have failed to show INCS to be superior to oral antihistamines. Compared to INCS, oral antihistamines have When looking at a much quicker onset second-generation of action. Depending on antihistamines, they are the antihistamine, generally considered symptoms should start equivalent in to improve within one to terms of efficacy. three hours. Oral Recommendation antihistamines are for a specific secondpreferred in patients generation antihistamine who cannot or will not can be based on patient administer INCS, need and pharmacist immediate relief, or have preference with occasional symptoms consideration of that do not require what the patient has daily treatment (i.e., previously tried. Some occasional pet dander studies have shown that exposure). loratadine has a slower onset of action (three Intranasal hours) compared to Antihistamines. fexofenadine and Intranasal antihistamines cetirizine (one hour). It is typically have limited use not well known if this is in practice, likely clinically significant, due to the especially for daily inconvenience of nasal antihistamine use. While administration of a second-generation medication that is orally antihistamines have available without any reduced sedation decrease in side compared to firsteffects. Intranasal generation, there is a antihistamines do have slight risk of sedation a rapid onset of action associated with their with an increase in use. Sedation is most effectiveness for nasal

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congestion over oral antihistamines. There is likely limited or no additional benefit for all other symptoms with intranasal ntihistamines. Intranasal antihistamines are recommended after failure of INCS or oral antihistamines. Intranasal Cromolyn. Intranasal cromolyn is available OTC. This medication is a mast-cell stabilizer that is thought to work by preventing histamine degranulation; thus, this medication should be used as a prophylactic treatment in allergic rhinitis. Intranasal cromolyn is less effective than INCS and oral ntihistamines, with frequent application of up to three to six times per day. Further, it takes three to seven days to see an effect from the medication, with full benefit not occurring until after two to four weeks of use. Thus, intranasal cromolyn is used for allergic rhinitis in patients who are pregnant, since there are minimal safety concerns compared to other therapies. It provides symptom relief for rhinorrhea, sneezing, and itching.

Side effects are minimal and are primarily limited to nasal tissue, including sneezing, nasal stinging and burning, and an unpleasant taste in the mouth. Decongestants. Both topical and systemic decongestants can be used to treat nasal congestion associated with allergic rhinitis due to their agonist activity on adrenergic receptors in the nasal mucosa. Topical decongestants should be avoided if a patient is using an INCS or intranasal antihistamine to avoid minimized drug absorption, drug binding issues, and excessive irritation of nasal mucosa. Evidence has shown that decongestants work well with oral antihistamines by shrinking swollen mucosa and improving breathing, which is helpful since oral antihistamines do not provide benefit in nasal congestion. Use of topical decongestants should be limited to three to five days to minimize risk of dependency on the decongestant or rebound congestion.

Immunotherapy. Immunotherapy is not a traditional pharmacotherapy option as for many years it was only available in a physicianâ€™s office; however, sublingual dosage forms have recently come on the market. Immunotherapy targets the underlying disease of allergic rhinitis by affecting basic immunologic mechanisms to induce immunological tolerance. This is the only disease-modifying therapy that provides clinically effective and sustained systemic relief after treatment while also preventing progression of the condition. Within the environment, patients are typically exposed to low doses of allergen at any time. With immunotherapy, the patient is given a high dose of allergen to build tolerance. There are two primary functions that cause immune tolerance, one being immune duration, where there is moderation of the immunological response to allergen. An induction of T cell regulation also occurs: Th1 cells

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produce interferon gamma, which stimulates B cells to produce IgG instead of IgE. This prevents an allergen from triggering an immune response. Further, suppression of local Th2 cells occurs, which redirects antibody production in favor of IgG and IgA. Presentation of the allergen to Th2 cells occurs, which ultimately blocks the allergeninduced action of mast cells. Patients receive immunotherapy subcutaneous injections every one to two weeks in a physicianâ€™s office while the dose is being increased, and then monthly as maintenance therapy. Immunotherapy must be administered in a physician office because life-threatening anaphylaxis, lthough rare, can occur. Allergens are administered at increasing concentrations to decrease the allergenspecific response when a patient is exposed. Sublingual immunotherapy tablets are administered at a fixed dose for 12 to 16 weeks before the

allergy season starts. These are not administered in a physicianâ€™s office because the risk of anaphylaxis does not carry over from the injections. There are no head-tohead studies comparing sublingual and subcutaneous immunotherapy; however, indirect studies suggest subcutaneous therapy is more effective, but sublingual therapy is safer. Special Populations. Cromolyn sodium is the drug of choice for allergic rhinitis in pregnancy due to its safety profile and topical administration; however, pharmacists must be mindful it takes up to four weeks to see optimal benefit. If an immediate-acting medication is needed, chlorpheniramine, a first-generation antihistamine is the most well-studied and safest antihistamine for use in pregnancy. Decongestants should be avoided in pregnancy due to risks of birth defects during the first trimester. Older adults should not use first-generation

antihistamines for allergic rhinitis due to sedation and potential for fall risk. Loratadine has the least risk of sedation among second-generation antihistamines. There is minimal concern for use of INCS in the geriatric population.

impermeable materials, removing stuffed toys from the patientâ€™s bedroom, and washing bedding weekly in hot water. One strategy to avoid outdoor mold includes avoiding activities that involve decayed plant material.

Nonpharmacologic Strategies Allergen avoidance is commonly recommended in managing allergic rhinitis. Despite common sense rationale of allergic rhinitis symptom improvement, clinical trials have not shown significant benefit of allergen avoidance. Limited benefit has been shown in persistent allergic rhinitis in both children and adults. Avoidance of allergens should never be recommended alone, but in conjunction with pharmacotherapy. Recommendations to reduce dust mite allergens include decreasing household humidity below 40 percent, removing mold with bleach, removing carpets from the patientâ€™s bedroom, encasing bedding in mite-

Patients can avoid indoor mold by lowering household humidity, venting areas of high humidity, repairing damp areas of the house (i.e., basements), and removing houseplants. Petrelated allergens may be reduced by removing the pet from the house or washing the pet weekly. Cockroaches can be reduced by keeping the kitchen clean, storing food in tightly closed containers, removing garbage regularly, and treating infestations with pesticides. Indoor allergens can be improved by use of a high-efficiency particulate air (HEPA) filter within the ventilation system and vacuum cleaner, removing wall-to-wall carpeting, and reducing exposure to cigarette smoke. Outdoor

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allergens such as pollutants and pollens can be assessed by the air quality index and pollen counts, respectively, and outdoor activities can be planned when these are low. When counts are high, keep windows and doors closed, shower and change clothes following outdoor activity, and use air conditioning. Nasal wetting agents (saline, propylene, or polyethylene glycol sprays or gels) are an inexpensive treatment option that may have some efficacy. Nasal irrigation with warm water (isotonic or hypertonic) via syringe or Neti Pots has become a popular option to treat nasal congestion. Irrigation flushes out mucus and irritants while also osmotically reducing inflammation. It may also reduce markers of inflammation for up to several hours after use. Studies looking at efficacy of nasal irrigation show conflicting results. Nasal irrigation

should only be used with distilled, sterile, or boiled tap water to reduce the risk of infection. Chronic use may not be recommended. Adverse effects include nasal irritation, burning, and stinging; these are more common when using hypertonic solutions. Patients have developed serious fungal infections when tap water was used for irrigation. Counsel patients to read the instructions for whichever product they purchase, as the different products may be handled differently. Patients should also be told to use nasal irrigation before using a nasal steroid. The Pharmacistâ€™s Role in Allergy Symptom Management Pharmacists play an important role in allergy management due to the availability of OTC medications to treat this condition. Despite the potential for complexity in diagnosis due to overlap of symptoms with other allergic conditions (i.e., the atopic triad), most patients do not seek diagnosis from a physician and will self-diagnose and

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selfmanage the condition. Pharmacists are often the primary source of health care advice for treatment of allergic rhinitis; thus, it is critical that pharmacists assess the patientâ€™s symptoms to confirm the diagnosis and recommend appropriate treatment. Further, pharmacists must ensure they stay up-todate on guidelines, OTC product transitions, and new therapeutic options. Despite being viewed as a benign condition, the respiratory symptoms associated with allergic rhinitis can have a significant impact on a patientâ€™s quality of life, i.e., physical functioning, energy level, sleep impairment, social functioning, and reduction in school or work performance. This highlights the mportance of pharmacist intervention, especially in the community pharmacy setting to offer optimal patient management. Most patients self-medicate with oral antihistamines, although intranasal corticosteroids are now suggested as firstline therapy. When

pharmacists see patients seeking OTC allergic rhinitis medications, they should attempt to assess the patientâ€™s symptoms and recommend appropriate therapy.

fitting medication administration into their schedule. Unsurprisingly, patients who did not perceive benefit from the medication were less likely to be adherent. This is Larger dosage volumes where pharmacists of INCS have been found can intervene to be associated with about appropriate decreased adherence. If expectations for onset the volume is too large, of benefit. This challenge it can result in irritation can likely be fixed, of nasal tissue and whereas a busy patient runoff down the back of schedule would push the throat. Pharmacists preference to oral should work with antihistamines due patients to use the to ease of administration lowest effective dose despite greater benefit (i.e., one spray in each with INCS. nostril vs. two sprays) to attempt to maximize Counseling is critical for patient adherence. optimal management of allergic rhinitis and Adherence may minimization of side vary based on the effects of recommended patientâ€™s lifestyle. therapies. Most INCS Overall adherence has side effects, especially significant room for those that are more improvement, which is significant, result from important since INCS improper administration need to be administered technique. Patients daily for optimal benefit. should be counseled to Patients with higher shake the bottle well education levels have and prime the inhaler been found to have when it has not been higher adherence. previously used, when it Patients with two or has been awhile since more dependent the last use, or when the children have been nozzle has been recently found to have lower cleaned. To prime the adherence, which may product, the inhaler be related to challenges should be aimed away

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from the patientâ€™s face and sprayed until a fine mist appears. The patient should then blow his or her nose before administration of the product. The tip of the applicator, not the full nozzle, should be inserted laterally into the nose, pointed away from the septum with the other nostril closed. This allows for decreased deposition of the medication on the septum and decreased trauma. While releasing a spray, patients should be counseled to gently sniff and that they will feel a light mist in their nose. They should be counseled to repeat the spray in the other nostril. Depending on symptom severity, a second dose may be required in each nostril. When counseling on oral antihistamines, pharmacists should be mindful of why the patient is using the antihistamine. If the patient is using the oral antihistamine for intermittent allergic rhinitis, it should be taken two to five hours before allergen exposure. If the patient

is taking the medication for seasonal or persistent allergic rhinitis, they should take the medication at the same time each day. Second-generation antihistamines should have minimal risk of sedation, so the medication can be administered whatever time of day is most convenient, ideally one to three hours before the most bothersome symptoms occur.

The authors, the Ohio Pharmacists Foundation and the Ohio Pharmacists Association disclaim any liability to you or your patients resulting from reliance solely upon the information contained herein. Bibliography for additional reading and inquiry is available upon request.

trustees and other individuals responsible for planning OPF continuing pharmacy education activities have no relevant financial relationships to disclose. Program 0129-0000-17005-H01P Release date: 5/15/17 Expiration date: 5/15/20 CPE Hours: 1.5 (0.15 CEU)

The Ohio Pharmacists Foundation Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

This lesson is a knowledge-based CPE activity and is targeted to pharmacists in all practice settings. Disclosure: The OPF

P h a r m a c y

C o m i c s

Artist: James Montague, R.Ph., Managed Care Academy Chair

â€œPill Bottle Evolutionâ€?

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continuing education quiz

Please print.

Allergic Rhinitis Review and Updates in Pharmacologic Management

Address_____________________________________________

1. Allergic rhinitis is a response to allergens mediated by: a. IgG. c. IgE. b. IgA. d. IgD.

Email_______________________________________________

Program 0129-0000-17-005-H01-P 0.15 CEU

Name________________________________________________

City, State, Zip______________________________________

NABP e-Profile ID____________Birthdate_________

(MMDD)

2. Individuals can have an allergic reaction to an allergen the first time they are exposed to the substance. a. True b. False

Return quiz to Correspondence Course, OPA, 2674 Federated Blvd, Columbus, OH 43235-4990

3. Patients with nonallergic rhinitis may experience all of the following signs and symptoms EXCEPT: a. frequent epistaxis. c. unilateral symptoms. b. allergic shiners. d. enlarged tonsils.

8. According to the Clinical Practice Guideline: Allergic Rhinitis released in 2015, which of the following is the preferred first-line agent to treat allergic rhinitis? a. Oral antihistamines b. Topical decongestants c. Intraocular antihistamines d. Intranasal corticosteroids

4. Risk factors for allergic rhinitis include all of the following EXCEPT: a. low socioeconomic status. b. genetic predisposition. c. eczema. d. positive reaction to allergy skin tests. 5. Pharmacists should monitor for which of the following comorbid conditions in patients with allergic rhinitis? a. COPD c. Asthma b. Acne d. Sinus infection

9. Leukotriene-receptor antagonists should be reserved for patients diagnosed with allergic rhinitis and: a. asthma. c. atopic dermatitis. b. conjunctivitis. d. COPD. 10. The onset of action of INCS is: a. 2-5 hours. c. 2-3 days. b. 12-24 hours. d. 2-4 weeks.

6. Patients should be referred to urgent care or a primary care provider for all of the following symptoms EXCEPT: a. facial pain. c. bilateral congestion. b. nosebleeds. d. loss of smell.

11. Compared to oral antihistamines, INCS provide greater relief for all of the following EXCEPT: a. nasal congestion. c. rhinorrhea. b. eye itching. d. sneezing.

7. Intermittent allergic rhinitis or seasonal allergic rhinitis is classified as symptoms occurring: a. <4 days per week OR <4 weeks. b. <4 days per week AND <4 weeks. c. >4 days per week OR >4 weeks. d. >4 days per week AND >4 weeks.

12. All of the following are true for use of intranasal cromolyn in allergic rhinitis EXCEPT it is: a. a mast-cell stabilizer. b. used prophylactically. c. the drug of choice in pregnancy. d. more effective than INCS.

Completely fill in the lettered box corresponding to your answer.

13. Allergen avoidance includes all of the following measures EXCEPT: a. removing carpet. b. removing stuffed toys. c. avoiding cigarette smoke. d. washing bedding in cold water.

1. 2. 3. 4. 5.

[a] [a] [a] [a] [a]

[b] [b] [b] [b] [b]

[c] [d]

6. [a] 7. [a] [c] [d] 8. [a] [c] [d] 9. [a] [c] [d] 10. [a]

[b] [b] [b] [b] [b]

[c] [c] [c] [c] [c]

[d] [d] [d] [d] [d]

11. [a] 12. [a] 13. [a] 14. [a] 15. [a]

[b] [b] [b] [b] [b]

[c] [d] [c] [d] [c] [d] [c] [d]

 This lesson is free of charge to members of the Arizona Pharmacy Association. 1. Rate this lesson: (Excellent) 5 4 3 2 1 (Poor) 2. Did it meet each of its objectives?  yes  no If no, list any unmet_______________________________ 3. Was the content balanced and without commercial bias?  yes  no If no, why?______________________ 4. Did the program meet your educational/practice needs?  yes  no 5. How long did it take you to read this lesson and complete the quiz? ________________ 6. Comments/future topics welcome.

14. Tap water should be boiled prior to use in nasal irrigation systems. a. True b. False 15. Patients should be counseled to shake and prime the INCS inhalers in all of the following situations EXCEPT: a. when the nozzle has been recently cleaned. b. when the bottle has not been previously used. c. before administration in the second nostril. d. if it has been awhile since the last use. To receive CPE credit, your quiz must be received no later than May 15, 2020. A passing grade of 80% must be attained. CPE credit for successfully completed quizzes will be uploaded to the CPE Monitor. CPE statements of credit can be printed from the CPE Monitor website. Send inquiries to opa@ohiopharmacists.org.

may 2017

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