Seasonal Allergic Rhinitis (Hay Fever)
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1 Seasonal Allergic Rhinitis (Hay Fever) Link to prescribing guidance: Clinical Presentation Link to CKS NICE guidance: History and Examination for patients Assess severity Reasons for early referral to an ENT specialist Differential diagnoses Refer to ENT Initial management Allergen avoidance Pharmacological treatments Allergic conjunctivitis If symptom control is poor, consider second line treatments Uncontrolled symptoms Review - consider alternative diagnosis If confident about diagnosis step-up treatment Consider referral Refer to an Allergist Refer to ENT
2 Clinical presentation Allergic rhinitis: 2 or symptoms for >1 hour most days is suggestive: sneezing rhinorrhoea blocked nose nasal pruritis with or without conjunctivitis Potential allergens: pollens and moulds animals mites: dust, storage, faecal pellets occupational induced: flour, latex, wood dust, enzyme, airborne proteins drug-induced aspirin, NSAIDs, alpha-blockers, topical sympathomimetics
3 History and Examination History is usually sufficient for diagnosis: sneezing, itchy nose, itchy palate other history helpful for diagnosis: seasonal at the same time each year? pollens or mould spores at home? pets or house dust mite at work? occupational allergens on holiday? remission suggests an environmental cause history suggestive of adenoid hypertrophy affects sleep Examine to exclude other causes: nasal polyps deviated nasal septum deformity of nasal bones, nasal turbinates or nasal cartilage crusting and granulations
4 Assess severity Timing of symptoms: intermittent symptoms: < 4 days per week; or < 4 consecutive weeks persistent symptoms: 4 days per week; and 4 consecutive weeks Severity of symptoms: mild disease: normal sleep no impairment of daily activities no impairment working and/or at school symptoms not troublesome moderate to severe disease is impairment of any of the activities or symptoms above
5 Reasons for early referral to an ENT specialist Refer to an ENT specialist if there is: unilateral nasal problems anatomical obstruction nasal septal perforation, ulceration, or collapse pain new polyps isolated rhinorrhoea blood stained discharge severe crusting within the nasal cavity recurrent infection periorbital cellulitis refer urgently severe sleep problems failure of initial treatment Nasal tumour should be suspected when unilateral obstruction is present, especially with: bleeding loss of sense of smell pain otalgia eye signs
6 Differential diagnoses Infectious rhinitis Non-allergic rhinitis: autonomic (vasomotor) drugs, e.g. NSAIDs, aspirin hormonal, e.g. pregnancy food and drink, alcohol, spicy food malignancy, e.g. lymphoma, melanoma immunodeficiency primary mucous defect, e.g. cystic fibrosis primary ciliary dyskinesia, e.g. Kartagener syndrome systemic/inflammatory, e.g. SLE, Sjogren non-allergic rhinitis with eosinophilia syndrome (NARES) Conditions which mimic rhinitis: deviated septum nasal polyps foreign bodies nasal tumours rare
7 patway Initial management allergen avoidance pharmacological treatment: intranasal corticosteroids oral antihistamines intranasal antihistamines saline douching/ sinus rinsing management of associated co-morbidities: asthma eczema pollen-food syndrome (PFS)
8 Allergen avoidance Occupational allergy: protective clothing/equipment avoidance may lead to a cure and prevent progression to asthma Household dust mite: dust mite impermeable bedding hot wash bedding at 55 C replace items which collect dust and cannot be easily cleaned good ventilation Animals: do not allow in the house if not acceptable, restrict presence in living areas brief trials of cat removal are generally ineffective as allergens remain for several months
9 Pharmacological treatments Consider one of the following first-line treatments (see table below for advantages and disadvantages for different treatments). Key characteristics of different first-line treatment options Relative efficacy - Relative efficacy - Onset of Dose frequency allergic rhinitis allergic conjunctivitis action Intranasal antihistamine* ++ None Within 15 minutes Two to four times daily Oral non-sedating Within 1 hour Once-daily options available antihistamine Intranasal Within 12 hours Once-daily options available corticosteroids * Not suitable for children < 5 years of age. Maximum efficacy takes days or weeks to develop Intranasal corticosteroids (can be bought over the counter): therapeutically superior to antihistamines nasal sprays are preferred: convenient less potential for adverse effects and less systemic bioavailability nasal drops are useful for severe obstruction start treatment 2 weeks before known allergen season Oral antihistamines (can be bought over the counter): effective for itch, sneeze, and rhinorrhoea and eye symptoms improve symptoms at non-nasal sites regular therapy is effective than 'as needed' second generation are preferred Intranasal antihistamines (can be bought over the counter): only recommended for intermittent allergic rhinitis useful as rescue therapy
10 Allergic conjunctivitis If allergic conjunctivitis is present, consider: oral antihistamine intraocular antihistamine intraocular chromones intranasal corticosteroid saline drops (in mild cases) Key characteristics of different first-line treatment options Relative efficacy - Relative efficacy - Onset of Dose frequency allergic rhinitis allergic conjunctivitis action Intranasal antihistamine* ++ None Within 15 minutes Two to four times daily Oral non-sedating Within 1 hour Once-daily options available antihistamine Intranasal Within 12 hours Once-daily options available corticosteroids * Not suitable for children < 5 years of age. Maximum efficacy takes days or weeks to develop
11 If confident about diagnosis step-up treatment Treatment if symptoms are uncontrolled with initial treatment What treatment can I offer if symptoms are uncontrolled with current treatment? Rerce advice about allergen avoidance, if applicable, and check compliance with first-line treatment. For people taking an oral antihistamine, add an intranasal corticosteroid and review after 2 to 4 weeks. For people using an intranasal corticosteroid, ensure they have a good technique. If they have, step up to the maximum licensed dose of the intranasal corticosteroid and review after 2 to 4 weeks. For people with residual symptoms on a maximum licensed dose of intranasal corticosteroid, continue with treatment and: If there is persistent nasal itch, sneezing, rhinorrhoea, or allergic conjunctivitis, add an oral antihistamine. If rhinorrhoea persists despite combined use of intranasal corticosteroid and antihistamine, add an intranasal antimuscarinic drug (ipratropium bromide). If nasal blockage is a problem, prescribe an intranasal decongestant for up to 7 days. For people requiring rapid resolution of severe symptoms that are impairing their quality of life, start or continue treatments to control symptoms long term, and consider prescribing a 5 10 day course of prednisolone: mg a day in adults and 10 mg a day in children. For people with persistent symptoms despite being on maximal medical therapy, refer for specialist assessment and management. Nasal spray and drop technique Nasal spray technique: Gently blow the nose to try and clear it. Shake the bottle well. Close off one nostril and put the nozzle in the other, directing it away from the midline. Tilt head forward slightly and keep the bottle upright. Squeeze a fine mist into the nose while breathing in slowly. Do not sniff hard. Breathe out through the mouth. Take a second spray in the same nostril then repeat this procedure for the other nostril. Nasal drop technique: Gently blow the nose to try and clear it. Shake the container well. Tilt the head backwards. Place the drops in the nostril (squeeze the container gently if necessary). Keep the head tilted and sniff gently to let the drops penetrate. Repeat for the other nostril, if required.
12 Consider referral Refer to a specialist if symptom control has not been adequately achieved. Refer to ENT if there is uncertainty about the diagnosis or any of the following are present: nasal perforation, ulceration, or collapse anatomical obstruction periorbital cellulitis refer urgently unilateral symptoms pain bloodstained discharge isolated rhinorrhoea polyps severe crusting within the nasal cavity recurrent infection severe sleep problems Refer to an allergist: if it has not been possible to confirm the responsible allergen and further testing is needed for consideration of allergen-specific immunotherapy/desensitisation
13 Information for Patients Advice for you at Asthma UK: Hay Fever at Bupa: Hay Fever from Patient Info UK: House Dust Mite and Pet Allergy from Patient Info UK: Persistent Rhinitis from Patient Info UK: Skin Prick Allergy Test from Patient Info UK:
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