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Allergic rhinitis and the one airway principle

A primary care nurse's quick guide to…

Allergic rhinitis and the one airway principle

Key learning points:

1.    Allergic rhinitis - of which hay fever is one type - is a common condition whose adverse impact is underestimated

2.    The 'one airway' principle is a management strategy based on the link between allergic rhinitis and asthma

3.    Primary care professionals should consider the two conditions and their treatment together

Pharmacy and supermarket shelves are stacked with hay fever remedies from early spring through high summer, so most people will recognise the term. Many may think of this form of seasonal allergic rhinitis as just a minor nuisance, nothing serious. However, the high profile of hay fever, and ready availability of over-the-counter treatments, may mean that the adverse impact is underestimated - and also its link with asthma. Hence the 'one airway' principle.

What is allergic rhinitis?

The term rhinitis describes inflammation of the membranes that line the nose (nasal mucosa). In allergic rhinitis, this is caused by an adverse immune reaction involving the production of excess immunoglobulin E (IgE), in response to environmental allergens.1,2,3

Hay fever is a type of seasonal allergic rhinitis, with symptoms occurring at the same time each year, in which the allergen is pollen.3

Allergic rhinitis is widely estimated to affect 20% of the UK population and to be increasing in incidence.4,5

The National Institute for Health and Care Excellence (NICE) states that the adverse impact of allergic rhinitis is underestimated; both it and the British Society of Allergy and Clinical Immunology (BSACI) cite research that show allergic rhinitis:

•   Significantly reduces quality of life.

•   Interferes with attendance and performance at school and work.

•   Results in substantial NHS costs.1,2

What is the 'one airway' principle?

The 'one airway, one disease' principle is a management strategy based on the now widely accepted link between allergic rhinitis and asthma.

The World Health Organisation (WHO) has an initiative dedicated to this association - Allergic Rhinitis and its Impact on Asthma (ARIA), set up in 1999.6 ARIA established the principle that asthma patients should be evaluated for allergic rhinitis, and vice versa, and that management of the two conditions should be considered together. This principle has been incorporated into the UK gold standard for allergic rhinitis management, the BSACI guideline.5,7,8,10

The link between allergic rhinitis and asthma relates to comorbidity, risk and aggravation of symptoms:

•   Allergic rhinitis and asthma often co-exist

Up to 85% of people with asthma also have allergic rhinitis (estimates vary widely), and up to two-fifths of allergic rhinitis patients suffer from asthma.1,9

•   People with allergic rhinitis are at increased risk of developing asthma

ARIA says that avoidance of the allergen(s) associated with a patient's allergic rhinitis may prevent the development of asthma.1,2,3,9

•   Rhinitis may aggravate asthma symptoms and lead to an exacerbation (asthma attack)

Allergy UK says that people with both asthma and allergic rhinitis have better asthma control and are less likely to be admitted to hospital for asthma if their rhinitis symptoms are well controlled.3

Spotting the signs and symptoms of allergic rhinitis

A person with rhinitis typically presents with one or more of the following symptoms: sneezing, nasal itching, nasal discharge and nasal blockage.1

The Primary Care Respiratory Society UK (PCRSUK) advises that practice nurses are well placed to take a patient history that explores symptoms to reveal differential diagnoses including infection, nose-picking, polyp and tumour. Infective, irritant and other non-allergic causes of rhinitis should also be ruled out.1,2

Symptoms that most strongly suggest allergic rhinitis are sneezing, itchy nose and palate, and bilateral itchy, red, swollen eyes, as well as those associated with asthma: coughing, wheezing, shortness of breath.2

Symptoms will coincide with exposure to known allergens, the most common of which are:

•   House dust mites (perennial allergic rhinitis).

•   Pollen (seasonal allergic rhinitis; hay fever).

•   Animal fur or feathers (perennial allergic rhinitis).2

Less common allergens include:

•   Moulds (seasonal or perennial allergic rhinitis).

•   Occupational allergens, eg flour, wood dust (occupational allergic rhinitis).2

Diagnosis of allergic rhinitis

A personal or family history of atopy (asthma, eczema, allergic rhinitis) makes a diagnosis of allergic rhinitis and/or asthma more likely.2

PCRSUK has produced a summary of the BSACI guideline for primary care professionals, which lists other signs that can be observed to aid diagnosis, including reduced nasal airflow and mouth-breathing.2,10

Skin prick, IgE or blood testing may be indicated if symptoms are persistent or poorly controlled.1,2

Allergic rhinitis is classified by intermittent versus persistent symptoms, and as mild versus moderate to severe according to impact on daily life.10

Management of allergic rhinitis

Allergen avoidance is fundamental to the management of allergic rhinitis. This can prove difficult given the ubiquity of the most common allergens; the NICE Clinical Knowledge Summary on allergic rhinitis provides advice that nurses can give to patients. Allergy UK provides further practical tips, including the use of a barrier balm around the nostrils.1,3

Pharmacological management involves non-sedating antihistamines, topical nasal corticosteroids or antihistamines, and anti-inflammatory eye drops - or a combination, depending on symptoms and severity.2

Immunotherapy may be considered for patients who are unresponsive to other treatment.2,3,5

Notes for primary care nursing practice

A significant proportion of rhinitis patients first present in primary care, and the majority of symptoms can be treated there. However, practitioners should remain alert to the possibility of rare and serious presentations and the need to refer; more details are provided in the BSACI guideline and PCRSUK summary.2,10

Research suggests that clinicians are failing to consider asthma and allergic rhinitis management together. Allergy UK cites research by MEDA Pharmaceuticals that found 41% of patients with both asthma and hay fever said they had never had a dedicated consultation to discuss the symptoms of the two conditions together. A further 22% said they had never discussed the conditions at the same time in a consultation even when it had come up.7

Primary care practitioners can help ensure that the one airway principle and best practice is being implemented; a presentation of allergic rhinitis should always trigger consideration of asthma and vice versa.

The future of practice

Allergy UK says: “The clear links between hay fever and asthma can no longer be underestimated and practice must change to meet this ever-growing challenge.”7

In April this year, ARIA announced the launch of the MASK Allergy Diary app, designed to enable patients to keep a daily record of allergic rhinitis and asthma symptoms and medication use.6

Resources

•   ARIA pocket guide to the management of allergic rhinitis and its impact on asthma, including an allergic rhinitis questionnaire and diagnosis guide: http://www.whiar.org/docs/ARIA_PG_08_View_WM.pdf

•   BSACI rhinitis (including allergic rhinitis) treatment algorithm: http://www.bsaci.org/Guidelines/Algorithm-RhinitisPCGL.pdf

•   PCRSUK summary of the BSACI guideline on management of allergic and non-allergic rhinitis, specifically for primary care professionals: http://www.nature.com/articles/pcrj201044

•   The MASK Allergy Diary app is available for Android and iPhone

References

1.    NICE. Clinical Knowledge Summaries. Allergic rhinitis. Revised October 2015. http://cks.nice.org.uk/allergic-rhinitis#!topicsummary(accessed 15 June 2016)

2.    Angie E et al. Management of allergic and non-allergic rhinitis: a primary care summary of the BSACI guideline. Primary Care Respiratory Journal (2010); 19(3): 217-222. http://www.nature.com/articles/pcrj201044

3.    Allergy UK. Hay fever and allergic rhinitis. Updated March 2015. https://www.allergyuk.org/hayfever-and-allergic-rhinitis/hay-fever-and-allergic-rhinitis(accessed 15 June 2016)

4.     Ryan D, Van Weel C, Bousquet J, Toskala E, Ahlstedt S, Palkonen S, Van Den Nieuwenhof L, Zuberbier T, Wickman M and Fokkens W. Primary care: the cornerstone of diagnosis of allergic rhinitis. Allergy(2008); 63: 981-989. http://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.2008.01653.x/full

5.     Broke JL et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 Revision. J Allergy Clin Immunol (2010); 126 (3): 466-76. http://www.bsaci.org/LiteratureRetrieve.aspx?ID=108794&A=SearchResult&SearchID=2171592&ObjectID=108794&ObjectType=6

6.     Allergic Rhinitis and its Impact on Asthma. Homepage. http://www.whiar.org(accessed 15 June 2016)

7.     Meda in partnership with Allergy UK. One airway, one diease: an expert report into the true impact of hay fever and asthma. April 2014. http://www.allergyuk.net/oneairway/files/assets/common/downloads/One%20Airway%20One%20Disease%20Report.pdf

8.     ARIA. Management of Allergic Rhinitis and its Impact on Asthma Pocket Guide. http://www.whiar.org/docs/ARIA_PG_08_View_WM.pdf

9.    Bousquet J et al. ARIA (Allergic Rhinitis and its Impact on Asthma) 2008 Update. ARIA. http://www.whiar.org/docs/ARIA-Report-2008.pdf

10.Scalding GK et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clinical & Experimental Allergy. Volume 38, Issue 1, January 2008, Pages: 19-42. http://www.bsaci.org/Default.aspx?PageID=8611251&A=SearchResult&SearchID=2171592&ObjectID=8611251&ObjectType=1