Allergic rhinitis (AR)

Question 1

Background

Answer 1

Allergic rhinitis is an IgE-mediated, inflammatory disorder of the nose that occurs when the nasal mucosa becomes exposed and sensitized to allergens, to produce symptoms

Question 2

Classes of AR

Answer 2

Seasonal — symptoms occur at the same time each year. If caused by grass and tree pollen allergens, it is also known as ‘hay fever’.
Perennial — symptoms occur throughout the year, typically due to allergens from house dust mites and animal dander.
Intermittent — symptoms occur for <4 days a week, or <4 consecutive weeks.
Persistent — symptoms occur for >4 days a week and for >4 consecutive weeks.
Occupational — symptoms due to exposure to allergens in the work environment.

BUT can also mild to severe.

Question 3

Signs & Symptoms

Answer 3

Typical: rhinorrhoea, congestion, sneezing and nasal itching.

Additional symptoms: postnasal drip, itching of the palate, and cough, and features suggestive of chronic nasal congestion : snoring, mouth breathing, and halitosis (bad breath).

Question 4

Diagnosis

Answer 4

Suspect AR after rhinitis been excluded and there’s typical symptoms.
Personal or family history of atopic conditions ( Asthma ,Eczema, AR).
AND if symptoms occur after known causative allergen; tree, grass and weed pollens, house dust mites, animal dander, occupational.

Question 5

Treatment

Answer 5

NON PHARMACOLOGICAL:
Advice and support, Use nasal irrigation with saline (rinse nasal cavity with spray, pump or squirt bottle - can buy OTC), AVOID ALLERGENS:
Pollen - Shower or wash hair after HIGH exposure, Avoid grassy areas, plan holidays to avoid pollen season, consider sun glasses or nasal barriers for high pollen count, monitor pollen count.
House dust mite - dont use allergen impermeable covers, synthetic pillows and acrylic duvets (toys off the bed), wash bedding & toys OW
Animal allergy - stay away from them
occupational - avoid allergen exposure, well ventilated work place

PHARMACOLOGICAL:
1ST LINE = IN corticosteroids or antihistamines (IN or non-sedating oral antihistamines), alone or combo.
- IN corticosteroids eg - mometasone furoate, fluticasone furoate, or fluticasone propionate - minimal systemic absorption.
- IN antihistamine eg - azelastine.
Less effective than corticosteroids
But combo INs more effective.
- non sedating antihistamine - cetrizine, loratidine, desoloratidine, acrivastine

AR MILD or INTERMITTENT/ BOTH:
Children = Antihistamine. IN/ORAL nonsedating.
Adolescents & adults = 1st line above.

AR Moderate to severe =
IN corticosteroid or IN combo Above

• Advise the person that the onset of action for IN corticosteroids is 6–8 hours after the first dose, but the max effect may not be seen until after 2 weeks.

IF symptoms intermittent STEP DOWN TREATMENT and STOP. IF persistent or on going exposure STEP UP or CONTINUE.
Advise the person to be reviewed after 2–4 weeks

Question 6

Treatment Failure

Answer 6

Check compliance.
Consider stepping up.

If sudden or severe nasal congestion: consider + a short-term IN decongestant: xylometazoline for up to 5–7 days, depending age (=/>6) and preparation used.

persistent watery rhinorrhoea despite a combo tried. ADD IN anticholinergic ipratropium bromide in =/>12.

persistent nasal itching and sneezing: options: + IN/oral antihistamine - used regularly, or give combo of INs eg Dymista (azelastine + fluticasone) or Ryaltris (olopatadine + mometasone) spray, if monotherapy with either FAILS.

Person with history of asthma + LTRA Montelukast to oral/IN antihistamine.

SEVERE uncontrolled symptoms affecting life. +SHORT COURSE oral steroid: eg Prednisolone 0.5mg/kg in morning for 5-10 days.

Question 7

Immunotherapy

Answer 7

Uses allergen vaccines can reduce symptoms of asthma and allergic rhino-conjunctivitis. Involves exposing the person to increasing amounts of an allergen to induce clinical and immunological tolerance.

SC therapy = initial dosing regimens followed by 4–6 weekly maintenance injections, usually for 3 years.

Sublingual - ALT IF tolerated, doses can be self-administered daily at home for, usually, 3 years.

AEs short lived - SC = itching, redness, swelling at the injection site, Sublingual = oropharyngeal itching, localized swelling

Question 8

Allergy testing

Answer 8

Arranged by GP.
Possible test include:
* Skin prick test
* Blood test (specific IgE test)
* Patch test

Question 9

Referral

Answer 9

Refer to ENT SPECIALIST:
- Red flag features suggesting ALT or serious diagnosis.
- Persistent symptoms despite optimal management
- Person wants immunotherapy
- Diagnosis is uncertain - allergy testing/ investigations are needed.