Allergic rhinitis

Seasonal allergic rhinitis (hay fever) affects 10–15% of people in the
UK and millions of patients rely on OTC medicines for treatment.
The symptoms of allergic rhinitis occur after an inflammatory
response involving the release of histamine which is initiated by allergens
being deposited on the nasal mucosa. Allergens responsible for
seasonal allergic rhinitis include grass pollens, tree pollens and fungal
mould spores. Perennial allergic rhinitis occurs when symptoms are
present all year round and is commonly caused by the house dust mite,
animal dander and feathers. Some patients may suffer from perennial
rhinitis which becomes worse in the summer months.
What you need to know
Age (approximate)
Baby, child, adult
Duration
Symptoms
Rhinorrhoea (runny nose)
Nasal congestion
Nasal itching
Watery eyes
Irritant eyes
Discharge from the eyes
Sneezing
Previous history
Associated conditions
Eczema
Asthma
Medication
Significance of questions and answers
Age
Symptoms of allergic rhinitis may start at any age, although its onset is
more common in children and young adults (the condition is most
common in those in their twenties and thirties). There is frequently
ALLERGIC RHINITIS 49
a family history of atopy in allergic rhinitis sufferers. Thus children of
allergic rhinitis sufferers are more likely to have the condition. The
condition often improves or resolves as the child gets older. The age of
the patient must be taken into account if any medication is to be
recommended. Young adults who may be taking examinations should
be borne in mind, because treatment that may cause drowsiness is best
avoided in these patients.
Duration
Sufferers will often present with seasonal rhinitis as soon as the pollen
count becomes high. Symptoms may start in April when tree
pollens appear and the hay fever season may start 1 month earlier in
the south than in the north of England. Hay fever peaks between the
months of May and July, when grass pollen levels are highest and
spells of good weather commonly cause patients to seek the pharmacist’s
advice. Anyone presenting with a summer cold, perhaps of
several weeks’ duration, may be suffering from hay fever. Fungal
spores are also a cause and are present slightly later, often until
September.
People can suffer from what they think are mild cold symptoms for
a long period, without knowing they have perennial rhinitis.
The PRODIGY classification of allergic rhinitis:
Intermittent. Occurs less than 4 days per week or for less than 4
weeks
Persistent. Occurs more than 4 days per week and for more than
4 weeks
Mild. All of the following – normal sleep; normal daily activities,
sport, leisure; normal work and school; symptoms not troublesome
Moderate. One or more of the following – abnormal sleep; impairment
of daily activities, sport, leisure; problems caused at work or
school; troublesome symptoms
(Source: www.prodigy.nhs.uk)
Symptoms
Rhinorrhoea
A runny nose is a commonly experienced symptom of allergic rhinitis.
The discharge is often thin, clear and watery, but can change to a
thicker, coloured, purulent one. This suggests a secondary infection,
although the treatment for allergic rhinitis is not altered. There is no
need for antibiotic treatment.
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Nasal congestion
The inflammatory response caused by the allergen produces vasodilatation
of the nasal blood vessels and so results in nasal congestion. Severe
congestion may result in headache and occasionally earache. Secondary
infection such as otitis media and sinusitis can occur (see p. 19).
Nasal itching
Nasal itching commonly occurs. Irritation is sometimes experienced
on the roof of the mouth.
Eye symptoms
The eyes may be itchy and also watery; it is thought these symptoms
are a result of tear duct congestion and also a direct effect of pollen
grains being caught in the eye, setting off a local inflammatory
response. Irritation of the nose by pollen probably contributes to eye
symptoms too. People who suffer severe symptoms of allergic rhinitis
may be hypersensitive to bright light (photophobic) and find that
wearing dark glasses is helpful.
Sneezing
In hay fever the allergic response usually starts with symptoms of
sneezing, then rhinorrhoea, progressing to nasal congestion. Classically,
symptoms of hay fever are more severe in the morning and in the
evening. This is because pollen rises during the day after being released
in the morning and then settles at night. Patients may also describe a
worsening of the condition on windy days as pollen is scattered, and a
reduction in symptoms when it rains, or after rain, as the pollen clears.
Conversely, in those allergic to fungal mould spores the symptoms
worsen in damp weather.
Previous history
There is commonly a history of hay fever going back over several
years. However, it can occur at any age, so the absence of any previous
history does not necessarily indicate that allergic rhinitis is not the
problem. The incidence of hay fever has risen during the last decade.
Pollution, particularly in urban areas, is thought to be at least partly
responsible for the trend.
Perennial rhinitis can usually be distinguished from seasonal rhinitis
by questioning about the timing and the occurrence of symptoms.
People who have had hay fever before will often consult the pharmacist
when symptoms are exacerbated in the summer months.
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Danger symptoms/associated conditions
When associated symptoms such as tightness of the chest, wheezing,
shortness of breath or coughing are present, immediate referral is
advised. These symptoms may herald the onset of an asthmatic attack.
Wheezing
Difficulty with breathing, possibly with a cough, suggests an asthmatic
attack. Some sufferers only experience asthma attacks during
the hay fever season (seasonal asthma). These episodes can be quite
severe and require referral. Seasonal asthmatics often do not have
appropriate medication at hand as their attacks occur so infrequently,
which puts them at greater risk.
Earache and facial pain
As with colds and flu (see p. 19), allergic rhinitis can be complicated
by secondary bacterial infection in the middle ear (otitis media) or the
sinuses (sinusitis). Both these conditions cause persisting severe pain.
Purulent conjunctivitis
Irritated watery eyes are a common accompaniment to allergic rhinitis.
Occasionally this allergic conjunctivitis is complicated by a secondary
infection. When this occurs, the eyes become more painful
(gritty sensation) and redder, and the discharge changes from being
clear and watery to coloured and sticky (purulent). Referral is needed.
Medication
The pharmacist must establish whether any prescription or OTC
medicines are being taken by the patient. Potential interactions between
prescribed medication and antihistamines can therefore be
identified.
It would be useful to know if any medicines have been tried already
to treat the symptoms, especially where there is a previous history of
allergic rhinitis. In particular, the pharmacist should be aware of the
potentiation of drowsiness by some antihistamines combined with
other medicines. This can lead to increased danger in certain occupations
and driving.
Failed medication
If symptoms are not adequately controlled with OTC preparations, an
appointment with the doctor may be worthwhile. Such an appointment
is useful to explore the patient’s beliefs and preconceptions about
hay fever and its management. It is also an opportunity to suggest
ideas for the next season.
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When to refer
Wheezing and shortness of breath
Tightness of chest
Painful ear
Painful sinuses
Purulent conjunctivitis
Failed medication
Treatment timescale
Improvement in symptoms should occur within a few days. If no
improvement is noted after 5 days, the patient might be referred to
the doctor for other therapy.
Management
Management is based on whether symptoms are intermittent or persistent
and mild or moderate. Options include antihistamines, nasal
steroids and sodium cromoglicate (sodium cromoglycate) in formulations
for the nose and eyes. OTC antihistamines and steroid nasal
sprays are effective in the treatment of allergic rhinitis. The choice of
treatment should be rational and based on the patient’s symptoms and
previous history where relevant.
Many cases of hay fever can be managed with OTC treatment and it
is reasonable for the pharmacist to recommend treatment. Patients
with symptoms that do not respond to OTC products can be referred
to the doctor at a later stage. Pharmacists also have an important role
in ensuring that patients know how to use any prescribed medicines
correctly (e.g. steroid nasal sprays, which must be used continuously
for the patient to benefit).
Antihistamines
Many pharmacists would consider these drugs to be the first-line
treatment for mild to moderate and intermittent symptoms of allergic
rhinitis. They are effective in reducing sneezing and rhinorrhoea,
less so in reducing nasal congestion. Non-sedating antihistamines
available OTC include acrivastine, cetirizine and loratadine. All are
effective in reducing the troublesome symptoms of hay fever and have
the advantage of causing less sedation than some of the older
antihistamines.
Cetirizine and loratadine are taken once daily while acrivastine is
taken three times daily. Recommended doses should not be exceeded.
ALLERGIC RHINITIS 53
For sale OTC, acrivastine, cetirizine and loratadine can be recommended
for children over 12 years.
While drowsiness is an extremely unlikely side-effect of any of the
three drugs, patients might be well advised to try the treatment for a
day before driving or operating machinery. Recent evidence suggests
that loratidine is less likely to have any sedative effect than the other
two, but the incidence of drowsiness is extremely small.
Acrivastine, cetirizine and loratadine may be used for other allergic
skin disorders such as perennial rhinitis and urticaria.
Older antihistamines, such as promethazine and diphenhydramine,
have a greater tendency to produce sedative effects. Indeed, both drugs
are available in the UK in OTC products promoted for the management
of temporary sleep disorders (see p. 311). The shorter half-life of
diphenhydramine (5–8 h compared with 8–12 h of promethazine)
should mean less likelihood of a morning hangover/drowsiness effect.
Other older antihistamines are relatively less sedative, such as
chlorphenamine (chlorpheniramine) and clemastine. Patients may
develop tolerance to their sedation effects. Anticholinergic activity is
very much lower among the newer drugs compared to the older drugs.
Interactions. The potential sedative effects of older antihistamines are
increased by alcohol, hypnotics, sedatives and anxiolytics. The alcohol
content of some OTC medicines should be remembered.
The plasma concentration of non-sedating antihistamines may be
increased by ritonavir; plasma concentration of loratadine may
be increased by amprenavir and cimetidine. There is a theoretical
possibility that antihistamines can antagonise the effects of betahistine.
Side-effects. The major side-effect of the older antihistamines is their
potential to cause drowsiness. Their anticholinergic activity may result
in a dry mouth, blurred vision, constipation and urinary retention.
These effects will be increased if the patient is already taking another
drug with anticholinergic effects (e.g. tricyclic antidepressants, neuroleptics).
At very high doses, antihistamines have CNS excitatory rather than
depressive effects. Such effects seem to be more likely to occur in
children. At toxic levels, there have been reports of fits being induced.
As a result, it has been suggested that antihistamines should be used
with care in epileptic patients. However, this appears to be a largely
theoretical risk.
Antihistamines are best avoided by patients with narrow- (closed-)
angle glaucoma, since the anticholinergic effects produced can cause
an increase in intraocular pressure. They should be used with caution
in patients with liver disease or prostatic hypertrophy.
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Decongestants
Oral or topical decongestants may be used to reduce nasal congestion
alone or in combination with an antihistamine. They can be useful in
patients starting to use a preventer such as a nasal corticosteroid (e.g.
beclometasone) or sodium cromoglicate where congestion can prevent
the drug from reaching the nasal mucosa. Topical decongestants can
cause rebound congestion, especially with prolonged use. They should
not be used for more than 1 week. Oral decongestants are occasionally
included such as pseudoephedrine. Their use, interactions and adverse
effects are considered in the section on ‘Colds and flu’ (see pp. 21–2).
Eye drops containing an antihistamine and sympathomimetic
combination are available and may be of value in troublesome eye
symptoms, particularly when symptoms are intermittent. The sympathomimetic
acts as a vasoconstrictor, reducing irritation and
redness. Some patients find that the vasoconstrictor causes painful
stinging when first applied. Eye drops that contain a vasoconstrictor
should not be used in patients who have glaucoma or who wear soft
contact lenses.
Steroid nasal sprays
Beclometasone nasal spray (aqueous pump rather than aerosol
version), fluticasone metered nasal spray and triamcinolone aqueous
nasal spray can be used for the treatment of seasonal allergic rhinitis.
A steroid nasal spray is the treatment of choice for moderate to
severe nasal symptoms that are continuous. The steroid acts to reduce
inflammation that has occurred as a result of the allergen’s action.
Regular use is essential for full benefit to be obtained and treatment
should be continued throughout the hay fever season. If symptoms of
hay fever are already present, the patient needs to know that it is likely
to take several days before the full treatment effect is reached.
Dryness and irritation of the nose and throat, and nosebleeds have
occasionally been reported; otherwise side-effects are rare. Beclometasone,
fluticasone and triamcinolone nasal sprays can be used in
patients over 18 years of age for up to 3 months. They should not be
recommended for pregnant women or for anyone with glaucoma.
Patients are sometimes alarmed by the term ‘steroid’, associating it
with potent oral steroids and possible side-effects. Therefore the
pharmacist needs to take account of these concerns in explanations
about the drug and how it works.
Sodium cromoglicate
Sodium cromoglicate is availableOTCas nasal drops or spray and as eye
drops. An OTC nasal spray product containing sodium cromoglicate
ALLERGIC RHINITIS 55
with a small amount of decongestant is available. The amount of
decongestant is said to be too small to produce rebound congestion.
Cromoglicate can be effective as a prophylactic if used correctly. It
should be started at least 1 week before the hay fever season is likely to
begin and then used continuously. There seem to be no significant
side-effects, although nasal irritation may occasionally occur.
Cromoglicate eye drops are effective for the treatment of eye symptoms
that are not controlled by antihistamines. Cromoglicate should
be used continuously to obtain full benefit. The eye drops should be
used four times a day. The eye drops contain the preservative benzalkonium
chloride and should not be used by wearers of soft contact
lenses.
Topical antihistamines
Nasal treatments
Azelastine and levocabastine are used in allergic rhinitis. The BNF
suggests that treatment should begin 2–3 weeks before the start of
the hay fever season. Azelastine and levocabastine are available as
aqueous nasal sprays. Their place in treatment is likely to be for mild
and intermittent symptoms. Azelastine can be used in adults and
children over 5 years of age; levocabastine can be used in adults
and children over 12 years of age. Advise the patient to keep the
head upright during use to prevent the liquid trickling into the throat
and causing an unpleasant taste.
Eye treatments
Levocabastine eye drops can be used in children over 12 years of age
and adults for the treatment of seasonal allergic conjunctivitis.
Further advice
1 Car windows and air vents should be kept closed while driving.
Otherwise a high pollen concentration inside the car can result.
2 Where house dust mite is identified as a problem, regular cleaning
of the house to maintain dust levels at a minimum can help. Special
vacuum cleaners are now on sale that are claimed to be particularly
effective.
Hay fever in practice
Case 1
A young man presents in late May. He asks what you can recommend
for hay fever. On questioning, he tells you that he has not had hay
fever before, but some of his friends get it and he thinks he has the
56 RESPIRATORY PROBLEMS
same thing. His eyes have been itching a little and are slightly watery,
and he has been sneezing for a few days. His nose has been runny and
now feels quite blocked. He will not be driving, but is a student at the
local sixth-form college and has exams coming up next week. He is
not taking any medicines.
The pharmacist’s view
This young man is experiencing the classic symptoms of hay fever for
the first time. The nasal symptoms are causing the most discomfort; he
has had rhinorrhoea and now has congestion so it would be reasonable
to recommend a corticosteroid nasal spray providing he is aged
18 or over. If he is under 18, an oral or topical antihistamine could be
recommended, bearing in mind that he is sitting for exams soon and so
any preparation that might cause drowsiness is best avoided. His eyes
are slightly irritated, but the symptoms are not very troublesome.
You know that he is not taking any other medicines, so you could
recommend acrivastine, loratadine or cetirizine. If the symptoms are
not better in a few days, he should see the doctor.
The doctor’s view
A corticosteroid nasal spray is likely to be more effective. If he cannot
use the OTC product because he is under 18, acrivastine, loratadine or
cetirizine would be worth a try. Even though they are generally nonsedating
they can cause drowsiness in some patients. The student
should be advised not to take his first dose just before the exam! If
his symptoms do not settle, then referral is appropriate. He may
benefit from sodium cromoglicate eye drops if his eye symptoms are
not fully controlled by the antihistamine. It is often worthwhile trying
an older antihistamine as an alternative because some people are
unaffected by the sedative properties, or an alternative non-sedating
one such as fexofenadine.
Case 2
Awoman in her early thirties wants some advice. She tells you that she
has hay fever and a blocked nose and is finding it difficult to breathe.
You find out that she has had the symptoms for a few days; they have
gradually got worse. She gets hay fever every summer and it is usually
controlled by chlorphenamine tablets, which she buys every year and
which she is taking at the moment. As a child, she suffered quite badly
from eczema and is still troubled by it occasionally. She tells you that
she has been a little wheezy for the past day or so, but she does not
have a cough, and has not coughed up any sputum. She is not taking
any other medicines.
ALLERGIC RHINITIS 57
The pharmacist’s view
This woman has a previous history of hay fever, which has, until now,
been dealt adequately with chlorphenamine tablets. Her symptoms
have worsened over a period of a few days and she is now wheezing. It
seems unlikely that she has a chest infection, which could have been a
possible cause of the symptoms. She should be referred to the doctor at
once since her symptoms suggest more serious implications such as
asthma.
The doctor’s view
This woman should be referred to her doctor directly. She almost
certainly has seasonal asthma. In addition to the hay fever treatment
recommended by her pharmacist, it is likely that she would also
benefit from a steroid inhaler such as beclometasone. Depending on
the severity of her symptoms, she would probably be prescribed a
beta-agonist, such as a salbutamol inhaler, as well. This consultation is
a complex one for a doctor to manage in the usual 10 min available in
view of the time required for: information-giving, explanation about
the nature of the problem, the rationale for the treatments and the
technique of using inhalers.
58 RESPIRATORY PRO