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Successful diagnosis and management of allergic rhinitis

Samantha Walker
RGN PhD
Director of Research
National Respiratory Training Centre
Warwick
E:s.walker@nrtc.org.uk

Allergic diseases are a common and increasing problem in Western societies,(1) the commonest manifestations of which are hayfever (seasonal allergic rhinitis) and asthma. Approximately 20% of the UK population (and about 75% of those with asthma(2)) suffer with some form of rhinitis, although the prevalence is highest in adolescents and young adults. Causes of rhinitis (which is defined as a collection of symptoms including a runny and/or blocked nose, sneezing, itching and sometimes postnasal drip [mucus running down the back of the throat] or conjunctivitis) are varied, but for simplicity they can be broadly grouped under headings of allergy and nonallergy. Their symptoms are similar, but allergic rhinitis is characterised by sneezing and itching, whereas the most common symptoms in nonallergic rhinitis are nasal blockage and postnasal drip.
As well as the obvious symptoms of itchy eyes and blocked nose, allergic rhinitis can cause nighttime sleep disturbance and associated problems with daytime concentration and reduced work productivity.(3) This is a significant problem in teenagers and young adults, the majority of whom are in fulltime study and whose work may suffer as a consequence. In a recent survey of 2,282 15-16-year-olds, 51% (1,153) reported symptoms indicative of hayfever, although only 21% (485) reported a diagnosis of hayfever by their nurse or doctor. Only 22% (502) reported taking any medication for their hayfever.(4)
In summary, hayfever is underdiagnosed and undertreated. This is particularly important in teenagers where key GCSE exams take place during the peak of the grass pollen season. Although rhinitis is easy to treat using a structured approach, it is helpful to differentiate between allergic and nonallergic rhinitis as the treatments may be different. In practice, simple questions can help you to discover the most likely cause and select the most appropriate treatment.

Mechanisms
Inhalation of allergen (eg, grass pollen) results in a classic sequence of events caused by an inappropriate immune response to otherwise harmless substances.(5) The classic signs of allergy - itching, redness and swelling - and its time course (immediate symptoms, usually occurring within 15 minutes of exposure) are caused mainly by the release of histamine, a potent chemical that causes itching due to irritation of nerve endings, redness due to vasodilation of blood vessels, and swelling due to increased vascular permeability via an antibody named immunoglobulin E (IgE). These signs of itching, redness and swelling mark the cornerstone of allergy diagnosis and, at a simplistic level, allow the health professional to differentiate quickly between allergic and nonallergic symptoms.
Other causes of rhinitis symptoms include infection (viral or bacterial), structural problems of the nose (eg, deviation of the nasal septum and polyps) and, less commonly, endocrine problems (hypothyroidism) and iatrogenic disease (eg, due to the combined oral contraceptive pill).

Diagnosis of allergic rhinitis
Rhinitis is defined as two or more of the following symptoms, which must last for an hour or more on most days: nasal blockage, sneezing, runny nose or nasal itch. Seasonal allergic rhinitis (hayfever) is usually diagnosed by a history of development or exacerbation of symptoms during the peak pollen season, usually May-July in the UK, which improve or disappear after the summer. Symptoms in the spring may be the result of exposure to birch pollen, whereas all-year-round symptoms may be caused by exposure to house dust mites or cat allergen. It may be difficult to relate symptoms to exposure, particularly when allergens are present all the time (eg, house dust mites), although an allergic trigger is more likely if sneezing and itching are present.
Identification of the responsible trigger may be possible by performing a skin prick test (which has been shown to be useful and feasible in general practice(4)) or by sending away for a specific IgE blood test. These tests are not always necessary, as successful treatment does not depend on allergen identification. Management depends on avoidance (where possible) and the regular administration of appropriate pharmacotherapy. The most important task during a consultation for rhinitis is to identify and appropriately treat those with an infection and, for the rest, to take a careful history to identify any avoidable triggers and treat according to the most troublesome symptom.

Management
To treat patients successfully, nurses should be familiar with current guidelines and available treatments.(6) It is important to treat rhinitis properly because:

  • Allergic rhinitis and asthma often coexist in the same patients.
  • Allergic rhinitis may be a risk factor for the development of asthma.(7)
  • Treatment with topical nasal corticosteroids appears to improve airways hyperresponsiveness.(8,9)
  • Patients with co-morbid asthma and rhinitis who are receiving treatment for allergic rhinitis have a significantly lower risk of attending accident and emergency departments and hospitalisations for asthma.(10)

It therefore may be possible to reduce asthma symptoms and the need for medication by improving management of rhinitis.
Current guidelines suggest a classification based on symptom duration and/or severity.(6) Sufferers should be categorised as having either intermittent or persistent symptoms, which are either mild or moderate to severe. Intermittent symptoms are defined as symptoms that occur for either less than four days per week or for less than four weeks in duration. Persistent symptoms are described as being present for more than four days per week and occurring for more than four weeks.

Treatment of allergic rhinitis
Guidelines recommend a combination of nonsedating antihistamines, long-acting topical nasal corticosteroids and anti-inflammatory eye drops.(6) Part of the management strategy should also be to arrange adequate follow-up and to encourage patient self-management for optimal symptom control.

Mild, intermittent symptoms
For those patients suffering only mild, intermittent symptoms for two to three weeks of the summer, simple allergen avoidance advice may be helpful, in combination with a nonsedating antihistamine. Examples include cetirizine (Zirtek; UCB), desloratadine (Neoclarityn; Schering-Plough) and fexofenadine (Telfast; Aventis), taken as required to control symptoms. If symptoms are confined to the eyes or nose, topical application of an antihistamine is useful - for example, azelastine (Optilast; Viatris), levocabastine (Livostin; Novartis) and sodium cromoglycate (Opticrom; Aventis). It is important to use a nonsedating antihistamine, as sedating antihistamines have also been shown to impair concentration and learning ability in children.(3) Second-generation antihistamines, on the other hand, have similar central nervous system (CNS) effects to placebo and significantly fewer CNS adverse events than their predecessors.

Persistent symptoms (moderate to severe)
For persistent, moderate-to-severe symptoms, the choice of drug treatment should be based on the primary symptom, although optimal symptom control is likely to be achieved with a combination of treatments.

Nasal blockage
The first-line treatment for nasal blockage is daily application of a topical nasal steroid,(11) such as fluticasone (Flixonase; Allen and Hanbury), budesonide (Rhinocort; AstraZeneca) and beclomethasone (Beconase; Allen and Hanbury). Antihistamines are less effective in the treatment of nasal blockage, although newer antihistamines such as desloratadine or fexofenadine may be helpful. Prescription of topical nasal sprays should always be accompanied by an explanation of device technique according to manufacturers' instructions.
Serious side-effects to nasal steroids are rare, and although beclomethasone has been associated with growth retardation in children, newer, more potent nasal corticosteroids do not appear to have the same effect. Patients should be followed up two weeks after the onset of symptoms to review effectiveness.

Rhinorrhoea, itching, sneezing
These symptoms usually respond best to a combination of a daily topical nasal steroid and a nonsedating antihistamine.

Eye symptoms
Eye symptoms occurring in isolation can be controlled by regular application of sodium cromoglycate eye drops (available over the counter). Patients should be advised that such drops should not be used when wearing contact lenses. If topical treatment is ineffective, or if symptoms occur with rhinitis, a nonsedating antihistamine is the most effective treatment. Corticosteroid eye drops should not be used unless under the supervision of an ophthalmologist.
 
Severe or uncontrolled symptoms
Possible options in those unresponsive to a combination of nasal corticosteroid sprays and antihistamines include: allergen avoidance measures, topical mast cell stabilisers, topical antihistamine nasal sprays, and a short course of oral steroids (eg, 20mg prednisolone daily for five days), although evidence in support of these interventions is limited.
Depot triamcinolone is no longer recommended in the UK because of concerns about safety.(12) Immunotherapy may be an option for those with severe hayfever unresponsive to medical treatment;(13) in the UK, immunotherapy may now be administered only in specialist centres with access to resuscitative facilities on hand. Details of clinics offering immunotherapy are available from the British Society for Allergy and Clinical Immunology (see Resource).

Summary  
Allergic rhinitis is a common condition that affects approximately 20% of the UK population. Symptoms are often trivialised by health professionals, although hayfever particularly is associated with impaired concentration and learning ability. Treatment is, in general, simple and effective when taken properly, and practice nurses who develop an interest in the subject can expect high levels of satisfaction from their patients. And who could ask for more than that?


References

  1. Strachan DP, et al. Worldwide variations in prevalence of symptoms of allergic rhinoconjunctivitis in children: the International Study of Asthma and Allergies in Childhood (ISAAC). Pediatr Allergy Immunol 1997;8:161-76.
  2. Walker SM, Sheikh A. Self-reported rhinitis is a significant problem for patients with asthma: results from a national (UK) survey. Prim Care Respir J 2005;14:83-7.
  3. Vuurman EPF, et al. Seasonal allergic rhinitis and anti-histamine effects on children's learning. Ann Allergy 1993;71:121-6.
  4. Walker SM, et al. Hayfever symptoms and medication use in UK teenagers. J Allergy Clin Immunol 2005;115(2):Abstract 794.
  5. Coombs RRA, Gell PGH. In: Gell PGH, Coombs RRA, editors. Clinical aspects of immunology. Oxford: Blackwell Scientific; 1963. p. 317-37.
  6. Bousquet J, et al. Allergic rhinitis and its impact on asthma (ARIA). Geneva: WHO; 2000.
  7. Wright AL, et al. Epidemiology of physician-diagnosed allergic rhinitis in childhood. Pediatrics 1994;94:895-901.
  8. Sotomayor H, et al. Seasonal increase of carbachol airway responsiveness in patients allergic to grass pollen. Reversal by corticosteroids. Am Rev Respir Dis 1984;130(56):58.
  9. Prieto L, et al. Effect of inhaled budesonide on seasonal changes in sensitivity and maximal response to methacholine in pollen-sensitive asthmatic subjects. Eur Respir J 1994;130:56-8.
  10. Crystal-Peters J, et al. Treating allergic rhinitis in patients with comorbid asthma: the risk of asthma-related hospitalizations and emergency department visits. J Allergy Clin Immunol 2002;109:57-62.
  11. Weiner JM, et al. Intranasal corticosteroids versus oral H1-receptor antagonists in allergic rhinitis: systemic review of randomised controlled trials. BMJ 1998;317:1624-9.
  12. Anon. Any place for depot triamcinolone in hayfever? Drugs Ther Bull 1999;37:17-18.
  13. Walker SM, et al. Grass pollen immunotherapy for seasonal rhinitis and asthma: a randomised, controlled trial. J Allergy Clin Immunol 2001;107:87-93.

Resource
British Society for Allergy and Clinical Immunology
W:www.bsaci.org