Allergic rhinitis, commonly known as hay fever, is an inflammatory allergic condition that affects around a quarter of adults in the UK. Unlike with some other allergic conditions, people don’t generally ‘grow out’ of hay fever – it is typically a lifelong problem.1,2 The UK’s most common allergens are grass, tree and weed pollens.
Many of those reading this article (and the author!) will have sneezed their way through summers as a teenager and it is easy to see allergic rhinitis as ‘one of those things’ – annoying, but not a big threat to health.
This is a misconception, and there is good evidence that performance at school and work are affected. One study of 1,834 students found those who dropped one or more grades between winter and summer exams were more likely to have symptoms of allergic rhinitis and to have used medication for allergic rhinitis than those whose grades stayed constant.3 Questionnaire-based studies have also demonstrated an effect on work productivity and quality of life in adults.2,4
Another facet of allergic rhinitis is its link with asthma. The upper and lower airways are continuous and lined with the same epithelium – allergic mediators such as histamine released in one or the other will affect both.5 Up to 38% of people with allergic rhinitis will also have asthma, and those who have both asthma and severe rhinitis have a fourfold risk of poorly controlled asthma compared with those who have asthma alone.2 Better recognition of the interaction between the two conditions could help to reduce deaths due to asthma and healthcare professionals should proactively ask about asthma symptoms when a patient presents with allergic rhinitis.6
The best approach
For patients who present with hay fever and have not tried any over the counter (OTC) remedies, it is appropriate for us to signpost to a pharmacist. Indeed, national guidance in England on the prescribing of OTC items says ‘a prescription for treatment of mild to moderate hay fever will not routinely be offered in primary care as the condition is appropriate for self-care’.7
Management can be with an antihistamine, eye drops or nasal spray, or a combination of these, all of which are available OTC for adults.2,8 Advice on avoiding allergens could be given at the time of purchase and is widely available online9 and some commissioners have clear pathways that start with the OTC purchase.10 Patients should understand that it may be up to a fortnight before nasal steroids take effect, so they should be used daily during the hay fever season rather than intermittently. There are many videos on how to use a nasal steroid.11
If a patient has reliably used double or triple therapy for a couple of months with no benefit, clinician input may be needed. The diagnosis should be reviewed to check for non-allergic rhinitis, which can be caused by a variety of conditions including nasal polyps, sinonasal tumours and NARES (non-allergic rhinitis with eosinophilia syndrome).2 A nasal antihistamine (not available OTC) might be added, or a short course of steroid nasal drops instead of a spray. A short course of oral steroids may be useful to offer quick relief for a key event such as an exam or a wedding, but the risks outweigh the benefits for longer-term use. A small number of patients (for example airline pilots) may have an occupational restriction to antihistamine use as they all cross the blood-brain barrier (even those sold as non-sedating). Fexofenadine is the least likely to cause sedation13 and occupational health review, or clearance from a regulatory body such as the Civil Aviation Authority, should be sought.
Referral to secondary care might be appropriate in some situations. Red flags for potential malignancy that require ENT referral include unilateral symptoms, recurrent nosebleeds, blood-stained nasal discharge or nasal pain.2 An obvious obstruction such as a polyp or deviated septum could indicate routine ENT referral. Symptoms of hay fever that persist despite optimal primary care management may be referred to an allergy clinic, although NHS access is patchy at best. Immunotherapy, available only via secondary care, is the only curative treatment.2 It has also been shown to prevent the onset of asthma in children with allergic rhinitis and to reduce asthma attacks and need for inhalers in those who already have asthma. Immunotherapy is underused in the UK, where we have fewer allergy specialists than other developed countries, and funding constraints mean most specialist centres will have only a few patients receiving immunotherapy at any one time.14 This should not stop us from referring when needed.
Hay fever is usually a mild or moderate condition, for which first-line management on an OTC basis will suffice. But we should be aware of those who will need referral to look for alternative diagnoses or for disease-modifying management of their allergic rhinitis.
Dr Toni Hazell is a GP in north London
- Allergy UK. What is hay fever? Link
- NICE CKS. Allergic rhinitis. Last updated August 2021. Link
- Walker S et al. Seasonal allergic rhinitis is associated with a detrimental effect on examination performance in United Kingdom teenagers. J Allergy Clin Immunol 2007; 120(2):381-387
- Szeinbach S et al. The impact of allergic rhinitis on work productivity. Prim Care Respir J 2007; 16(2):98-105
- Giavina-Bianchi P et al. United airway disease: current perspectives. J Asthma Allergy 2016;11(9):93-100.
- Office for National Statistics. Deaths from asthma, respiratory disease, chronic obstructive pulmonary disease and flu, England and Wales, 2001-2018 occurrences. 2020. Link
- NHS England. Conditions for which over the counter items should not be routinely prescribed in primary care: Guidance for CCGs. 2018. Link
- British Society for Allergy and Clinical Immunology. Most common allergies. Link
- Allergy UK. Four seasons: managing your asthma or allergic rhinitis throughout the seasons. Link
- Nottinghamshire Area Prescribing Committee. Allergic rhinoconjunctivitis treatment pathway (adults). Last reviewed March 2022. Link
- Asthma and Lung UK. How to use nasal spray. Link
- Zhang W et al. Impact of allergen immunotherapy in allergic asthma. Immunotherapy 2018;10(7):579-593
- Mann R et al. Sedation with ‘non-sedating’ antihistamines: four prescription-event monitoring studies in general practice. Commentary: Reporting of adverse events is worth the effort BMJ 2000; 320:1184
- British Society for Allergy and Clinical Immunology. First BSACI registry for immunotherapy report. 2020. Link