Hayfever & Allergy

Question 1

Intranasal corticosteroids.

Answer 1

Intranasal corticosteroids
- Pregnancy: Safe to use
- Breastfeeding: Safe to use
- Children: Should not be used regularly in people <18 years
- First line treatment in moderate to severe cases
- Reduce inflammation and decrease mucus production
- Maximum effect is achieved after several days of regular use, however they have an effect on symptoms such as blocked nose and rhinorrhoea within 3-7 hours of starting treatment. They are still effective if used on a PRN basis
- Contraindicated in severe nasal infection
- May delay healing if the patient has had recent nasal surgery or trauma
- Adverse effects: systemic SEs are rare
o Common: nasal stinging, itching, sneezing, sore throat, dry mouth, cough

Question 2

List the common intranasal corticosteroids and briefly talk about them.

Answer 2

• Beclomethasone
• Beconase Allergy and Hayfever 12 Hour® - nasal spray: 50mcg per dose
• Children: Okay >3 years
• Dosage:
  o Adult: 2 sprays into each nostril BD. May be reduced to 1 spray into each nostril BD when symptoms are controlled
  o Child: 3-12 years – 1 spray into each nostril BD. May be reduced to once daily when symptoms are controlled
• Budesonide
• Rhinocort Hayfever® - nasal spray: 32mcg per dose, 64mcg per dose
• Children: Okay >6 years
• Dosage:
  o Adult, child >6 years: Initially: 128mcg into each nostril once daily, or 64mcg into each nostril BD. Maintenance: 32-64mcg into each nostril, once daily
• Fluticasone
• Beconase Allergy and Hayfever 24 Hour® - nasal spray: 50mcg per dose
• Children: Okay >12 years
• Dosage:
  o Adult, child >12 years: initially 2 sprays into each nostril once daily, reduce to 1 spray once daily when symptoms are controlled

Question 3

Intranasal Antihistamines.

Answer 3

Intranasal Antihistamines
- Pregnancy: Avoid use – B3 (use an oral antihistamine instead)
- Breastfeeding: Limited data
- Adverse effects:
o Common: Local irritation
o Infrequent: nose bleed, headache
- In the treatment of allergic rhinitis, they are as effective as oral antihistamines, but less effective than intranasal corticosteroids
- A combination of an intranasal antihistamine with an intranasal decongestant (if needed) may be a suitable alternative to intranasal corticosteroids

• Azelastine
• Azep® - nasal spray: 1mg/mL
• Children: Okay in >5 years
• Dosage:
  o Adult, child >5 – 1 spray into each nostril BD
• Common adverse effect = metallic taste
• Suitable for long term use
• Levocabastine
• Livostin® - nasal spray: 0.5mg/mL
• Children: Okay in >6 years
• Dosage:
  o Adult, child >5: 2 sprays into each nostril BD, (increased up to a maximum of QID)

Question 4

Oral decongestants.

Answer 4

Oral Decongestants
- Pregnancy: Avoid use, particularly in the first trimester. Category B2
- Breastfeeding: Safe
- Children: okay to use >2
- Sympathomimetics (they act on the alpha adrenoreceptors)
- Cause vasoconstriction of dilated nasal vessels – thereby decreasing swelling and congestion
- Contraindications:
o Severe or uncontrolled hypertension or severe coronary artery disease
o MAOI treatment
- Side effects:
o Common: CNS stimulation, nervousness, excitability, dizziness, insomnia
o Infrequent: tachycardia, palpitations
o Rare: Hallucinations, arrhythmias, hypertension, seizures, ischaemic colitis
- Special considerations:
o Diabetes – may affect blood glucose control
o Heart disease – increased risk of arrhythmias
o Hypertension – BP may increase
o Prostatic hypertrophy – symptoms may be exacerbated
o Hyperthyroidism – increases sensitivity to sympathomimetics
o Closed angle glaucoma – may induce an acute attack
- Oral decongestants are less effect than intranasal decongestants, but do not cause rebound congestion
- Do not use CR products in children
- Effectiveness trials on phenylephrine are lacking
- Studies have shown that on average, pseudoephedrine caused only a slight increase in systolic BP and heart rate in people who were normotensive or had controlled hypertension

Question 5

Intranasal Decongestants.

Answer 5

Intranasal Decongestants
- Pregnancy: Safe to use **
- Breastfeeding: Safe to use **
- Children: Avoid use in infants 4-5 days)
o Rare: Hypertension, nausea, nervousness, dizziness, insomnia, headache
- Ephedrine is preferred in children
- Ephedrine is less likely to cause rebound symptoms
- Keep dose and length of treatment (up to 5 days) to a minimum to reduce the risk of rebound congestion (which may take several weeks to reverse)
- Oral products are preferred for prolonged use

Question 6

What product would you recommend for young infant, pregnant woman, patients with heart disease, HT, hyperthyroidism, diabetes, or on MAOIs?

Answer 6

Normal Saline (0.9% NaCl)

• Fess Nasal Spray® - saline nasal spray
• Fess Little Noses® - saline nasal drops (for infants)
• Pregnancy: Preferred option
• Children: Preferred option (can use in infants <6 months)
• Dosage: Maximum of 8 spray per nostril, every 2-3 hours as needed
• Preferred for patients with heart disease, HT, hyperthyroidism, diabetes or on a MAOI
• Infants: If nasal congestion impairs feeding, use a few drops in each nostril just before the feed to loosen and liquefy mucus secretions

Question 7

What are the SMx of hay fever (allergic rhinitis)?

Answer 7

• runny nose (rhinorrhoea)
• nasal congestion
• sneezing
• itching of any of the nose, eyes, ears or throat
• watery, red, irritated eyes

Symptoms are typically triggered by environmental allergens such as pollen and are worse at times of high pollen count.