PATIENT EDUCATION AND TREATMENT COMPLIANCE IN ALLERGIC RHINITIS IN THE UNITED STATES Michael S. Blaiss, MD Clinical Professor of Pediatrics and Medicine University of Tennessee Health Science Center Memphis, Tennessee

AAAAI. The Allergy Report. Available at: Accessed February 12, 2008; Dykewicz MS, Fineman S. Ann Allergy Asthma Immunol. 1998;81(5, pt 2): Basic Approaches to the Management of Allergic Rhinitis Environmental Control Measures Education Pharmacotherapy Allergen Immunotherapy

Medication adherence The degree to which the persons behavior corresponds with the agreed recommendations from a health care provider. – World Health Organization

Definitions of Adherence and Compliance Adherence is the term used to describe the patients behavior of taking drugs correctly – in the right dose, with the right frequency, and at the correct time A critical aspect of adherence is the patients involvement in deciding whether or not to take the drugs Compliance means the patient does what he or she has been told to do by the doctor/pharmacist

8 The Educated Patient Takes a more active role in medical care Is often more compliant with treatment programs Is better informed about how to maintain a healthy state

Adherence in Pharmacologic Therapy

61,655 adults in 31,470 households screened for AIA 2500 subjects18 yrs and older current allergies were interviewed by telephone about their condition and treatment (average time about 35 minutes) Criteria for participation in the survey Diagnosed by healthcare practitioner with allergic rhinitis, nasal allergies, or hay fever Symptomatic (yes or no) Received treatment for their nasal allergies within the previous 12 months In parallel, healthcare practitioners were interviewed Interviews were conducted 2006 Funded and maintained by an educational grant through Nycomed and Sunovion Allergies in America-Study Design

Reason Stopped Taking Nasal Allergy Prescription Q94. Have you ever stopped taking a nasal allergy medicine prescribed by your doctor because…. N=2,500

Failed to Follow Physician Instructions Q108. People with nasal allergies sometimes fail to follow their physicians instructions about their medicines for allergies. Have you ever failed to take an allergy medicine as prescribed because of …… N=2,500

Why Changed Medicine for Nasal Allergies Q81b. Why have you changed nasal allergy medicines? Anything else? Base: Have changed nasal allergy medicines N=1,723

Nasal Allergy Patients Request New Medications When They Are Dissatisfied Q82a. Have you ever asked your doctor to change your nasal allergy medication because you were dissatisfied with it? N=2,500 No, 66% Yes, 34%

Side Effects of Allergy Medicines Q90. How many of the medicines that you have taken for allergy had the following types of side effects --- all, most, some, few or none? N=2,500

Severity of Side Effects of Nasal Allergy Medicines Are Moderately to Extremely Bothersome

Patients Get Monies Worth from Rx Medicines Q30. Overall, do your patients feel they get their moneys worth out of prescription medicines for nasal allergies? N=400 PQ97. Overall, do you feel that patients get their moneys worth out of prescription medicines for nasal allergies? N=2,500

Nasal Allergy Patients Agree in a Need for Patient Education Q45. How much need do you think there is for better education of PEOPLE WITH NASAL ALLERGIES about their condition and its treatment? Do you think there is a… N=400 PQ113. How much need do you think there is for better education of people with nasal allergies about their condition and its treatment? N=2,500

Meltzer EO. Allergy Asthma Proc. 2005;26(6): Shah SR. Clin Ther. 2003;25: Shimoda N. Biol. Pharm. Bull. 1995;18: INCS: Intranasal corticosteroid Importance of Formulation Characteristics in Intranasal Corticosteroid Delivery Additives and preservatives can cause tolerability issues by irritating the mucosal membranes and causing nasal drying, and they can confer an unpleasant odor or taste to an INCS formulation Characteristics such as delivery device and spray volume can affect a patients perception and experience with a particular INCS The relative osmotic pressure, or tonicity, of an INCS can modulate nasal absorption and retention, thereby potentially influencing the clinical efficacy

INSTonicityBKC Potassium sorbateAlcohol Poly- sorbate Propylene glycolCMC CiclesonideHypotonic++ Fluticasone propionate Isotonic+_+*++ Triamcinolone acetonide Isotonic++ FlunisolideIsotonic Mometasone furoate Isotonic+++ BudesonideIsotonic++++ Fluticasone Furoate Isotonic++++ Abbreviations: BKC, benzalkonium chloride; CMC, carboxymethylcellulose Symbols:, negative; +, positive * Phenylethyl alcohol Sorbitol Meltzer EO. Ann Allergy Asthma Immunol. 2007;98: VERAMYST ® (fluticasone furoate) Prescribing Information. 2007, GlaxoSmithKline Formulation Components of INCS Products CMC to increase viscosity PPG to act as a moisturizer

Symptom Improvement With 50% WMC Loh CY, et al. Allergy. 2004;59(11): Patient Education: Adherence % Patients 100 Forgot Medication (1-5 times) <50% Compliance (WMC) Nasal Itch n=49n=7 11 N=63 Rhinorrhea Nasal Obstruction WMC = weight of medication consumed. % Symptom Improvement 65 Sneezing

Epistaxis and INS Technique Of 559 consecutive patients using an intranasal steroid for more than 3 months 28 patients (5%) reported epistaxis within the prior 2 months Of the 32 reported sides of bleeding (unilateral and bilateral combined) 25 episodes (78%) were on the same side as the hand used to apply the spray. A strong correlation was found between the side of bleeding and both the hand used (p < 0.001) and the handedness of the patient (p < 0.002) Benninger MS. Ear Nose Throat J. Aug 2008;87(8):

How to Use a Nasal Spray

Adherence in Allergen Immunotherapy

The charts of the 381 patients enrolled in an AIT program at Wilford Hall Medical Center as of September 2000 were retrospectively evaluated for compliance with their AIT regimen. Compliance was defined as receiving an allergy injection within the past 3 months at the time of chart review, a similar criterion used by previous studies.

Dropout Rate from SCIT Allergy Clinic in Eau Claire, WI-dropout rate from SCIT before completion of SCIT for 3-5 years Before 3 years-12% failed to complete SCIT Five most common reasons for stopping SCIT Concurrent medical problem Noncompliance Change of residence Inconvenience Allergic reactions One percent quit early due to reactions to immunotherapy Rhodes BJ. Ann Allergy Asthma Immunol 1999;82:281–286.

Increasing Adherence to Treatment Keep it simple Deliver it effectively Avoid its problems Call it medicine Provide it readily Review its usage Link it with lifestyle Put it in writing Support it psychosocially Minimize the cost Meltzer EO. J Allergy Clin Immunol. 1995;95:

Conclusions There are numerous factors that led to poor adherence in the treatment of allergic rhinitis in the USA We need to do a better job in educating patients about this condition We need to develop new strategies to partnership with our patients to improve buy-in for medical management and immunotherapy REMEMBER-no matter how great the treatment is, the outcome will be poor if the patient is non-adherent