CITY & HACKNEY ELIC EAST LONDON INTEGRATED CARE

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Camron Whitehead
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1 CITY & HACKNEY ELIC EAST LONDON INTEGRATED CARE ALLERGIC RHINITIS (JOINT HOMERTON / ELIC PATHWAY) 1. Classification (See ARIA guidelines for full details) Allergic rhinitis is common and affects >20% of UK population. Symptoms include sneezing, itchy nose and palate, rhinorrhoea, post nasal drip, bilateral nasal obstruction and eye symptoms (watering/itching). There may also be cough wheeze or SOB Symptoms may be intermittent or persistent and can be mild or moderate/severe in which case sleep/activities of daily living and school or work would be affected. Allergic rhinitis can also be divided into seasonal (grass or tree pollen), perennial (house dust mite (HDM) or occupational. 2. Differential diagnosis: Infective ( acute or chronic/bacterial or fungal) Idiopathic Drug induced (beta blockers, oral contraceptive, aspirin and NSAID, topical decongestant, ACEI, chlorpromazine ) Vasomotor Autonomic (responds to anticholinergic) Hormonal-pregnancy, puberty, HRT, COC Atrophic-usually overuse of topical decongestant Neoplastic-if unilateral Part of a systemic disorder- Cialiary dyskinesia/cystic Fibrosis/Youngs /Kartageners /SLE/RA/ HIV/ Wegeners/ Sarcoid/ Hypothyroidism/pregnancy/ Samters triad/churg Strauss 3. Diagnosis: History-ask about exacerbating sites, seasons, factors and occupation and symptom severity and secretions (clear, discoloured, bloodstained-if bloodstained then refer ENT) Ask about symptoms of asthma and diagnose and treat as appropriate Examine nose by anterior rhinoscopy-look for pale swollen nasal mucosa with enlarged inferior turbinates. Also look for polyps (translucent,pale grey/gelatinous/non-sensitive) or other causes of nasal symptoms e.g. deviated nasal septum 1

2 Consider RAST testing Refer ENT if persistent unilateral obstruction or blood stained discharge Refer ENT if unilateral polyp Refer Allergy clinic if symptoms not controlled on maximum therapy AND desensitisation is indicated (see info later) 4. Treatment: (as per Homerton Joint Formulary) Stage 1 Oral antihistamine for mild symptoms such loratidine or cetirizine (avoid sedating antihistamines) Manufacturer advises avoid in pregnancy and breastfeeding although not known to be harmful. Stage 2 Intra nasal steroid (INS) spray is drug of choice in moderate to severe ideally, corticosteroid nasal sprays should be started two weeks before patients are likely to become symptomatic if known Beclometasone is the most cost effective with high bioavailable (higher absorption). If also on beclometasone inhaler for management of asthma then Fluticasone which has lower bioavailability. In children can use Fluticasone from 4yr (1 st choice) or Beclometasone nasal spray from age 6. Nasal Steroid sprays can be used in pregnancy and breastfeeding Must give leaflet and clear instructions about use of spray. Look down Use R hand for L nostril and L hand for R nostril Sniff gently or not at all. Most common cause of treatment failure is wrong technique. INS should be tried for 2-3m before deciding it is not of benefit Can add eye drops (sodium cromoglicate etc) for eye symptoms Stage 3 Combine INS and oral antihistamine and eye drops Stage 4 Try saline nasal douching (good evidence for this) Take a mug of tepid boiled cooled water Add a pinch of salt and a pinch of sodium bicarbonate and mix well (or use plain water) Pour into the palm of the hand and sniff up into the nostrils repeat the last step 3 times 2

3 Gargle with the remaining solution and allow the fluid to slip over the soft palate as it is expelled to help clear the post nasal space Stage 5 Try a different INS (mometasone) Stage 6 If patient has asthma then treat as appropriate and can add montelukast For short term relief for e.g. exam or wedding, can use nasal decongestant or short course oral steroid. Avoid using intra-muscular steroid preparations. Topical anticholinergic( ipratropium bromide) for watery rhinorhoea - mainly for those with non-atopic rhinitis. Allergen avoidance for those who are motivated and mono-allergic. Grade D Evidence (weak)-see attached sheet. Stage 7 RAST testing for cat, dog, HDM (house dust mite) and pollen - blood test can be done on green form at homerton lab.(see info later) Stage 8 ELIC ENT referral-for nasendoscopy to look for polyps or enlarged adenoid Referral to Allergy Clinic if desensitisation (immunotherapy) is indicated (for pollen and dust mite) RAST TESTING: Can investigate with RAST tests which are available to GP s via Homerton(request on usual green blood form) Radioallergosorbent testing or RAST is a method employed in allergy testing (type 1 allergy - IgE mediated). The patient s serum is incubated with a solid phase allergen and the amount of allergen-specific IgE quantified with radiolabelled anti-ige. Many different allergens may be tested (e.g. house dust mite, grass pollen, cat epithelium) for with one sample of serum. Although the RAST was the first type of test described, radioisotopes are no longer used in the detection of specific IgE and hence the term RAST is now used as an abbreviation for an in vitro assay for specific IgE. These tests are in vitro and therefore provide results corresponding to the concentration of specific IgE in the patient s serum. They do not necessarily reflect the amount of mast cell fixed antibody 3

4 NOT a marker of the severity of reactions the patient has experienced or is likely to experience in the future. The result is a marker of sensitisation and IgE response but may have no correlation with symptoms Negative RAST test does not exclude significant allergy-may have tested for the wrong allergen or may be a false negative. Examples of allergens tested for as possible causes of type 1 hypersensitivity reactions: Food - peanuts; tree nuts including walnut, almond, hazelnut; eggs; milk; shrimp; prawns Inhalant allergens - pollens (grass (symptoms in June July August)), weed, tree (symptoms in March April May); house dust mite; cat dander; dog dander Venom (wasp, bee) A negative RAST may not exclude significant allergy. Blood samples are sent from Homerton to The Doctors Lab ( The website gives lists of tests grouped into appropriate profiles e.g. pollens or foods. The cost for a RAST test is 16-as far as we can find out GP s do not pay per individual item. DESENSITISATION: Desensitisation is by injectable subcutaneous immunotherapy. It is contraindicated in perennial asthma. Seasonal asthmatics may benefit from immunotherapy. For grass and tree pollen this can be done by 7-10 weekly injections pre-season each year for 3 years. It is possible to have sublingual desensitisation for grass pollen only but this needs to be taken every day for 3 years. For house dust mite injections are given every week for 10 weeks then every 6 weeks for 3 years Allergen avoidance Most of these measures carry Grade D evidence (weak) but some patients may wish to try these measures particularly if mono-allergic 4

5 1. General measures: Mattress, duvet and pillow covers wash bedding at 55 and damp wipe mite proof covers every 2w remove carpets-hard wood floor use ascaricides on carpets and furnishings minimise dust-collecting objects remove soft toys from bed leather plastic or vinyl furniture do not dry clothes on radiator and remove infrequently worn clothing from bedroom 2. Pollen avoidance: Nasal filters (good evidence but pt needs to buy them and likely to be cosmetically unacceptable) Minimise early morning activity Avoid going out after thunderstorm or on windy day Wear wraparound sunglasses Avoid mowing/newly mown grass Plan hols to avoid pollen season Keep windows closed at home and in car-use AC if needed Shower and wash hair when you get home Bathe eyes and douche nose frequently Stay indoors if high pollen count Bring in washing before evening pollen increase 3. Cat allergen: Remove cat then clean house/steam clean wall and shampoo carpets Keep cat our of bedroom Wash cat weekly Remove carpets, replace with hardwood floor Air Filtration units Increase ventilation by fan/ac/open windows (From BSACI and ARIA guidelines in collaboration with Dr Rajakulasingam and Mr Eynon Lewis and Dr Dominic Roberts 2001) Reviewed

Seasonal Allergic Rhinitis (Hay Fever)

Seasonal Allergic Rhinitis (Hay Fever) Link to prescribing guidance: http://www.enhertsccg.nhs.uk/ear-nose-and-oropharynx Clinical Presentation Link to CKS NICE guidance: https://cks.nice.org.uk/allergicrhinitis