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A patient-centred approach to seasonal allergic rhinitis

Monica H Fenn RN 
Asthma and Allergy Nurse Specialist
Imperial College Healthcare NHS Trust

Kathryn E Powrie BN RN
Asthma and Allergy Nurse Specialist
Imperial College Healthcare NHS Trust

Allergic rhinitis affects 20% of the population in the UK and is the most common reason for visits to GPs, placing a considerable burden on healthcare resources

Allergic rhinitis is inflammation of the nasal mucosa causing symptoms of itch, sneeze, rhinorrhoea and nasal congestion. It often affects the orbits, sinus and ears, with associated co-morbidities of pain, decreased hearing and sense of smell. It is estimated to affect around 500 million people globally.1

Previously classified as seasonal or perennial (all year) the World Health Organization initiative 'Allergic Rhinitis and its Impact on Asthma' (ARIA) redefined the classification as intermittent or persistent to reflect duration, with severity as mild or moderate-to-severe, focusing on treatment goals to reflect global management (see Figure 1).

[[Fig 1. Fenn]]

The British Society for Allergy and Clinical Immunology (BSACI) guidelines include seasonal allergy alongside ARIA reflecting UK practice in diagnosis and treatment.2 The term 'rhinoconjunctivitis' includes ocular symptoms of itchy, watery, burning/irritable eyes with redness and injection of the conjunctiva and peri-orbital oedema, which occur in 70% of cases with 33% experiencing moderate/severe symptoms.3

Atopy is the genetic predisposition to produce immunoglobulin E (IgE) to environmental proteins. With one atopic parent, risk of atopy is doubled (maternal influence strongest) and with both parents this is quadrupled.3 The prevalence of atopic disease is highest in teenagers, with 27.3% of 18 year olds having atopic rhinitis, with male predominance.4 Allergy is the clinical expression of disease such as atopic dermatitis, allergic rhinitis and asthma, and the progression from one to another of these related diseases is often referred to as the 'allergic march'.

Seasonal allergic rhinitis (SAR) involves an immune mechanism whereby sensitisation to pollen protein produces specific allergic antibody (IgE) formation. Re-exposure to pollen cross-links IgE triggering rupture of mast cells, releasing histamine and other mediators. This results in the allergic cascade producing immediate symptoms of itch, sneezing, nasal discharge and subsequent late-phase inflammation causing chronic obstruction, hyposmia, postnasal discharge and nasal hyperactivity (an exaggerated response to environmental irritants such as cold air, perfume and tobacco smoke).

SAR can be a precursor for asthma. Studies have shown that bronchial hyperactivity is present in 50% of those with rhinitis and 80% of asthmatics also have rhinitis.5,6

Variously known as hayfever, spring catarrh and summer cold, seasonal allergic rhinoconjunctivitis (SARC) refers to pollen allergy in countries that have seasonal variations (mostly northern hemisphere). In the UK this occurs in April/May for tree pollens (predominantly birch) and May to September for grass (primarily timothy) and weeds, with a two-week delay in onset from the south to north owing to climatic difference. Grass pollen allergy affects over 95% SAR sufferers in the UK.3

Diagnosis
In SAR the history is the most important feature in making a diagnosis; nasal-ocular symptoms and pollen exposure being indicative. On examination the allergic salute, transverse nasal crease, allergic shiners/Dennie-Morgan sign (bags or lines under the eyes) give visual clues. Physical examination of the nose may reveal polyps and assist with differential diagnosis.
The BSACI website algorithm for the management of rhinitis in primary care provides a useful summary for treatments, differential diagnosis and when to refer.7

Skin-prick testing (SPT) demonstrates allergen specific IgE and supports the diagnosis of allergic disease. In conjunction with clinical history, SPTs are a valuable tool in identifying relevant allergens, assisting in education about allergen avoidance (Table 1).8 If SPTs are not available (SPTs cannot be performed if patient is taking antihistamines) SAR can be diagnosed on clinical history, signs, symptoms and a treatment trial.

[[Tab 1. Fenn]]
 
Case study
Mrs S has attended surgery with her 15 year old son. Their doctor's impression is that Mrs S has severe SARC and her son SAR with seasonal wheeze. The doctor requests SPTs for both to aero-allergens and spirometry on her son. The results will guide the delivery of patient education regarding allergen avoidance and use of medication including nasal sprays and inhalers.

In appearance Mrs S looks very tired, with big bags under red watery eyes (Dennie-Morgan sign). Her son frequently wipes his nose in an upwards direction (allergic salute), has a nasal crease, both are sneezing and sniffing frequently. Neither uses
any medication.

During skin prick testing Mrs S describes what prompted them to come and see the doctor. She is not sleeping well and frequently wakes sneezing with a blocked but runny nose. She goes to bed around 2am when she is exhausted enough to sleep. She does not wake refreshed and feels fatigued. She stays indoors as much as possible in the summer, has stopped attending her son's sporting fixtures and has given up gardening (her stress reliever). She drives to and teaches at the same school that he attends. Her son has also had nights disturbed with frequent coughing and sneezing.

The day of an exam they both woke late. Driving to school she nearly hit another car, frightening them both. Her husband tolerates disturbed nights, loves gardening and attends all their son's summer fixtures but is worried as he has started wheezing during matches.

Their son, a gifted all-round sportsperson, already competes in high-level competition, and plans to do a sports science degree. Her husband is frustrated that she spends summer indoors severely restricting their leisure activities. Equally, she feels miserable. She realises that she is not performing at her best, affecting both her students and family. The potential implications for her son and her students' futures, the impact of her restricted lifestyle on the family and the risk she poses to others have all hit home.

Mrs S is positive to tree, grass and weed pollens, and her son positive to grass pollen only, with spirometry within normal limits.

Mrs S dislikes using medication but mentions that her brother, who owns a gardening business, has been much better since starting injections at the hospital for his hayfever.8 A colleague has told her about an allergy shot he used to get for hayfever and she wonders if she could have it - unlike her brother she cannot arrange time off school.

Her son is worried about taking medication because of drug regulations in competitive sport and concerned that not taking treatment will mean he performs poorly at school and sports.

Impact on quality of life
SAR impacts on quality of life, disturbing sleep, affecting
performance at work and at school. SAR is known to decrease learning capacity, cause irritability, fatigue, headache, daytime somnolence, impair cognitive function, decrease performance and productivity and reduce psychological wellbeing.9

Research has shown that SAR affects examination results adversely; in one study 28% of students on SAR treatment were using sedating antihistamines, which are known to have an adverse effect on attention span, vigilance, speed and working memory and affecting motivation and activity.10 SAR impacts upon family members and social life, and is often underestimated and trivialised by healthcare professionals and patients.11

Asthma and rhinitis
Research shows that allergic rhinitis often precedes the development of asthma and that rhinitis is usually diagnosed later than asthma with pre-existing symptoms in 69% of adults and 76% of children in a global study population. In this study, 75% of respondents had fears about the effects of medication and experienced a detrimental impact in their daily life.12

Immunotherapy research shows that early treatment of SAR in children defers asthma onset and reduces sensitisation to other allergens, underlining the 'one airway, one disease' concept and the importance of early assessment and treatment of co-existing disease.5

There is increased incidence of exercise-induced
bronchospasm and atopy in highly trained athletes (58% in
athletes compared to 38% in non-athlete controls). In a UK athlete team questionnaire, 60% gave a positive response to having hayfever but only 5% had a formal diagnosis. The risk of poor management, underperformance and ongoing morbidity implemented an allergy screening and management programme.13

Difficulty implementing avoidance measures and increased allergen exposure in competitive sport (usually outdoor, high season with increased mouth breathing) places focus on effective medication regimens, with a caveat on avoiding oral decongestant treatments and high dose steroids as these appear in the banned substances anti-doping code.13

Spirometry is preferable to peak expiratory flow because it allows clearer identification of airflow obstruction, and the results are less dependent on effort.14 However, it is important to remember that a normal spirogram does not exclude the diagnosis of asthma. Home peak flow reading is helpful to demonstrate any diurnal variation and treatment effectiveness.

Treatment
Guidelines recommend a combination of non-sedating antihistamines (nsAH), topical nasal corticosteroids (INS) and anti-inflammatory (chromone or antihistamine) eye drops. In moderate-to-severe SAR, daily treatment is recommended. Treatment should commentce two weeks pre-seasonally to optimise efficacy and depends on good device technique. It is vital to demonstrate correct nasal spray technique (Box 1). Spraying onto the septum and sniffing should be avoided. Patient involvement in the selection of an inhaler device aids concordance and adherence to treatment.14

[[Box 1. Fenn]]
 
Allergen-specific immunotherapy (IT) is the only treatment able to modify the disease process, is highly effective in reducing symptoms and has the potential for long-term remission.2 Reserved for those not responding to conventional pharmacotherapy IT involves repeated administration over three years. It is available subcutaneously (SCIT) and sublingually (SLIT) and requires referral to an allergy specialist for evaluation and consideration. In the case study, Mrs S mentions that her brother frequently attends hospital for hayfever injections - this suggests he is receiving SCIT, which is only available in specialist centres (www.bsaci.org), performed by trained personnel with resuscitation facilities as there is a risk of systemic reaction.

In the UK SCIT is contraindicated in chronic asthma. SLIT is effective for those with rhinitis and asthma with a good safety profile. It is taken once daily at home for three years.2 As there is theoretical risk of anaphylaxis, the first dose is given at a specialist centre. For both routes treatment effectiveness relies on appropriate patient selection (mono-sensitised to pollen only with demonstrable specific IgE). Patients who remain symptomatic despite pre-seasonal and daily triple therapy (INS, nsAH and chromone eye drops) should be referred to a specialist.

Historically, many patients have received intramuscular steroid injections given as a depot. This practice is not recommended in the UK, as the risk-to-benefit ratio is poor, with side-effects including fat atrophy at the injection site, aseptic necrosis of the femur and persistent effects on bones and eyes.3 A short course of oral steroids (prednisolone) is helpful in gaining control of extreme exacerbations or for significant life events and may be helpful for key examinations.

Patient education
Patient education for the case study mother and son needs to take their health beliefs and concerns into account in order to provide individual treatment plans. They should be made aware of other treatment modalities (inhaled corticosteroid, anti-leukotrienes, SLIT/SCIT) to manage ongoing disease and the importance of never smoking. The key patient education points are:

  • Treatment goals - reduction in symptoms restoring life quality.
  • Use of medication on a daily basis started two weeks before the onset of their pollen season.
  • How to use nasal spray and inhaler.
  • Address concerns regarding medication side-effects.
  • Practical pollen avoidance advice.
  • Active treatment monitoring.

Conclusion
SAR is under-recognised, impacts significantly on quality of life and can be a precursor to asthma. Evaluating symptom severity and identification of the patient's pollen season will direct treatment options and assist avoidance advice.

References
1.    Brožek JL, Bousquet J, Baena-Cagnani CE, Bonini S, Canonica GW, Casale TB, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 Revision. J Allergy Clin Immunol 2010;126(3):466-76.
2.    Scadding GK, Durham SR, Mirakian R et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Ex Allergy 2008;38(1):19-42.
3.    Scadding GK, Fokkens WJ. Fast Facts: Rhinitis (2nd edn). Abingdon: Health Press; 2007.
4.    Kurukulaaratchy RJ, Karmaus W, Raza A, Matthews S, Roberts G, Arshad SH. The influence of gender and atopy on the natural history of rhinitis in the first 18 years of life. Clin Exp Allergy 2011;41(6):851-9.
5.    Leynaert B, Neukirch C, Kony S, Guénégou A, Bousquet J, Aubier M, et al. Association between asthma and rhinitis according to atopic sensitization in a population-based study. J Allergy Clin Immunol 2004;113(1):86-93.
6.    Kariyawasam HH, Scadding GK. Seasonal allergic rhinitis: fluticasone propionate and fluticasone furoate therapy evaluated. J Asthma Allergy 2010;3:19-28.
7.    British Society for Allergy and Clinical Immunology (BSACI). Available from: www.bsaci.org/index.php?option=com_docman&task=doc_download&gid=54
8.    Lim MY, Leong JL. Allergic rhinitis: evidence-based practice. Singapore Med J 2010;51(7):542-9.
9.    Carah Santos CT. The effect of rhinitis on sleep, quality of life and daytime somnolence and fatigue. In: Mahmoudi M, ed. Allergy and Asthma: Practical Diagnosis and Management. New York: McGrawHill; 2008.
10.    Walker S, Khan-Wasti S, Fletcher M, Cullinan P, Harris J, Sheikh A. Seasonal allergic rhinitis is associated with a detrimental effect on examination performance in United Kingdom teenagers: case-control study. J Allergy Clin Immunol 2007;120(2):381-7.
11.    Ryan D, Van Weel C, Bousquet J et al. Primary care: the cornerstone of diagnosis of allergic rhinitis. Allergy 2008;63(8):981-9.
12.    Valovirta E, Pawankar R. Survey on the impact of comorbid allergic rhinitis in patients with asthma. BMC Pulm Med 2006;6(Suppl 1):S3.
13.    Dijkstra HP, Robson-Ansley P. The prevalence and current opinion of treatment of allergic rhinitis in elite athletes. Curr Opin Allergy Clin Immunol 2011;11(2):103-8.