How often do you ask a child in the exam chair if her eyes were “ever” itchy or watery? When I started to ask this question to every patient in my pediatric population, it was quite evident that there was an undiscovered gold mine in my anterior segment practice. Allergies
in the pediatric population are trending upward in a startling and truly dangerous manner.
Statistically, epidemiological studies and surveys in the U.S. have illustrated approximately 50 million patients suffer from some form of allergy and 20 to 25 percent with ocular allergies
.1 Dissecting these numbers further, Abelson et al found that approximately 40 percent of children were affected by allergic conjunctivitis.2 After digging through the literature, my mission statement became how to effect change today in the hearts and minds of optometric physicians to start treating pediatric patients in a more aggressive manner in their practices.
What's trending in ocular allergy treatment
What’s in it for me?
The short answer is everything to lose but immensely more to gain! Although children can take more time to examine and be confounding in their history, I have found easy open-ended questions helpful to slice through for the purpose of time management (See box). The queries might seem simplistic, but they have streamlined and improved chair time in my busy clinical setting. Furthermore, parents are both impressed with the clear responses from their children and in many cases shocked that the children have any symptoms of allergies. Once the child acknowledges the symptoms of the condition, the parent will begin to engage you. This becomes your platform to educate the parent about chronic allergy treatment and management, whether it is seasonal allergic conjunctivitis (SAC), perennial allergic conjunctivitis (PAC), or vernal keratoconjunctivitis (VKC). At this moment, the doctor has waged the adherence war and achieved a significant victory.
Next: The pharmacy conundrum
The pharmacy conundrum
Now that you have the diagnosis, the next logical step is selecting your medication of choice. Let me take a moment to emphasize this tremendous opportunity to diffuse a bomb: be the doctor and use your power of the electronic pen. We all live in an age where the pharmacy benefit manager makes many calls beyond our wishes, but let me share a pearl. If you desire to prescribe a specific product, it is within your doctoral right to specify “brand medically necessary.” These words essentially bar pharmacists from substituting a generic product of their choice without your permission. In addition, I would suggest looking at your state laws for further guidance because there are always slight differences in legal doctrine.
Nonpharmacologic care for ocular allergies
Another hurdle is who carries the purse strings, the parent or caregiver. We might think we captured them hook, line, and sinker with education, but ultimately in some cases there are financial obstacles. I do not take these situations lightly, yet I don’t harp on them either to hemorrhage valuable chair time. Once you have stated your case and actively suggested a rebate card to defray a substantial amount of the cost for products such as Lastacaft (alcaftadine, Allergan), Pataday (olopatadine hydrochloride, Alcon), and Bepreve (bepotastine besilate, Bausch + Lomb), your job is mostly done.
I say mostly done because the “rub” is step therapies with certain generic products that might be dictated by the patient’s Rx benefit for which you must once again be flexible. A quick takeaway in your decision tree is patient comfort when given the typical popular choice between generic forms of Elestat (epinastine, Allergan) and Optivar (azelastine, Meda). The ratio of ocular burning and stinging is highly in favor with epinastine with 1 to 10 percent of patients experiencing these symptoms comparatively to 30 percent with azelastine.3,4 Finally, if there is a tremendous financial burden below the poverty level, I have utilized the RxHope patient assistance program as a viable alternative.
Next: The lion, the drop, and the wardrobe
The lion, the drop, and the wardrobe
I never tell a pediatric patient the following words: medication, drop, or pill. From the eyes and ears perspective of a young child, including my 4-year-old daughter Hannah, and even younger adolescents, the thought of taking any medicinal therapy is emotionally upsetting and confusing.5 How do I confront these situations? The chief golden rule is to have a cheerful and positive attitude while explaining how the medication will help them improve their allergy symptoms.6 Additionally, with a huge assist from fairy tales and fictional characters, I utilize the following vocabulary in place of drops and pills: magic potions and magic beans. I find that children feel more at home with these analogies, which leads to far less resistance when it is time to take their medication at night before bedtime. Finally, I encourage parents to empower their child to include them in the experience by holding the bottle together to instill the “potion” into their eyes.
Nasal sprays for allergies
Think twice, treat once, improve quality of life
Although allergic conjunctivitis might seem annoying and not as glamorous as glaucoma and macular degeneration; nonetheless, it can truly change a patient’s life. From my clinical experience, it astonishes me time and again where my pediatric population will come back for a follow up or a comprehensive examination with a smile on their face in order to tell me that they did not miss school due to their “itchy and scratchy” eyes. Personally, these moments are gratifying and have increased my drive to treat more in this disease state.
1. Centers for Disease Control and Prevention. “CDC Fast Facts A-Z,” Vital Health Statistics, 2003. Asthma and Allergy Foundation of America. http://www.aafa.org/display.cfm?id=9&sub=30.
2. Abelson MB, Granet D. Ocular allergy in pediatric practice. Curr Allergy Asthma Rep. 2006; 6(4):306-11.
3. Elestat [package insert]. Irvine, CA; Allergan; December 2011.
4. Optivar [package insert]. Somerset, NJ; Meda Pharmaceuticals; April 2009.
5. Iliades, Chris, Bass PF ed. “10 Ways to Get Kids to Take Medicine.” everyday HEALTH. Everyday Health Media, 3 February 2011. http://www.everydayhealth.com/kids-health/10-ways-to-get-kids-to-take-me...
. Accessed on 1/10/15
6. Food and Drug Administration. “Giving Medicine to Children.” FDA. US Department of Health and Human Services, 12 March 2013. http://www.fda.gov/ForConsumers/ConsumerUpdates/ConsumerUpdatesEnEspanol...
. Accessed on 1/10/15.