Hayfever: clinical review

Why it is important to diagnose and effectively manage seasonal allergic rhinitis, including advice on pre-emptively managing patients, comorbidities and allergen avoidance.

Section 1: Epidemiology and aetiology
Section 2: Making the diagnosis
Section 3: Managing the condition
Section 4: Prognosis
Section 5: Case study
Section 6: Evidence base


Section 1: Epidemiology and aetiology

Hayfever (seasonal allergic rhinitis) is often trivialised but it can cause severe symptoms, and reduce quality of life and educational performance. Hayfever can progress to, or worsen, asthma.

Primary healthcare professionals are ideally placed to help patients with hayfever, including pre-emptively selecting patients who have been badly affected in previous years and advising them on an early start to regular preventive therapy or allergen-specific immunotherapy.

Hayfever was rare two hundred years ago but is now highly prevalent, affecting around a quarter of the population. A similar increase in prevalence has been seen in other allergic and immunological disorders and this may relate to lack of early exposure to infective organisms.

Hayfever is an allergic disease involving a misplaced immunological response which is more suited to removing parasitic worms. In allergic patients, immunoglobulin E (IgE) is generated locally in response to nasal contact with pollen – the sensitisation phase. Subsequent contact with the same pollen allows IgE-mediated mast cell degranulation to occur. Powerful mediators such as histamine, prostaglandins and leukotrienes are released, causing symptoms of sneezing, rhinorrhoea, itch and blockage in the nose, and, in most patients, ocular itching, watering and redness.

Pollen asthma may also occur, particularly during thunderstorms when pollen grains are disrupted into smaller particles. Hayfever is associated with poor asthma control, similar to the effect of smoking and worse than that of poor concordance with asthma inhalers.1

Other comorbidities include problems with sleep, poor concentration and a deterioration in work or school performance.


Section 2: Making the diagnosis

History
A history of classic symptoms occurring at a particular time of year (spring for tree pollens, summer for grass pollens, autumn for weed pollens and mould spores) usually suggests a diagnosis of hayfever. It can be difficult to distinguish hayfever from viral colds, but viral colds usually start with a sore throat, last only a few days and do not tend to cause itching or eye symptoms.

Investigations
Confirmation of allergen specific IgE can be made by skin prick testing or more often, in primary care, by a blood test. False positive IgE results can occur, so a screening test for IgE to multiple allergens is inadvisable. Instead, specific pollens suggested by the history should be tested.

False negative results are also possible, especially in the early stage of the disease when IgE may still be localised to the nasal mucosa. If the history is sufficiently clear then the blood test could be omitted and a trial of therapy instituted.


Section 3: Managing the condition

Aim to achieve control of hayfever quickly to reduce its burden, aid concordance and minimise the risk of progression to asthma. This approach should also reduce the costs associated with hayfever.

Control measures include avoidance of relevant allergens, pharmacotherapy, immunotherapy and, importantly, patient education.2

Allergen avoidance
It is clear that allergen avoidance works because hayfever is in abeyance outside of the relevant pollen season (although in some patients perennial allergens may cause symptoms throughout the year). However, it is difficult for patients to avoid allergens sufficiently to completely improve symptoms. Some advice to offer patients is detailed below.

Taking a holiday during the time of highest pollen peaks (the last fortnight in June for grass pollen) to a place further south where the pollen season has already finished can help patients, but this is not possible for many.

Patients should plan outdoor activities for the middle of the day when pollen grains have risen into the atmosphere and try to avoid being outside in the evening when pollen descends as the air cools. Bring in any washing that is drying outside before the evening for the same reason.

Hair washing helps to remove pollen and prevents deposition on pillows. Wrap-around sunglasses reduce eye contact with pollen, but, because eye symptoms are triggered by nasal reflexes too, patients should also use a barrier balm inside the nostrils.

Nasal douching with salt water after pollen exposure can reduce symptoms. Sterimar spray is prescribable.

Pharmacotherapy

Intranasal corticosteroids (INS)
Meta-analyses show that intranasal corticosteroids are more effective than antihistamines and leukotrienes and they should be prescribed for anyone with symptoms that are more than a mild nuisance. Regular daily use, starting a week or two before expected symptom onset, gives optimal results.

Patients need reassurance that the corticosteroid in the current generation of nasal sprays are minimally systemically bioavailable and INS can be used even in small children. It is important to demonstrate the correct use of a spray.

Antihistamines
Antihistamines are routinely suggested as first-line therapy but are actually better as an addition to INS if required. They reduce itch, nasal running and sneezing, and eye symptoms, but have little effect on blockage. Sedating first generation molecules should never be used as they add psychomotor retardation to that caused by hayfever.

Oral antihistamines are less effective and slower in onset than intranasal sprays, but they do improve non-nasal or eye symptoms, such as itchy skin. Some patients dislike the taste of intranasal azelastine.

Combination
A combined spray which contains a corticosteroid (fluticasone propionate) and a nasal antihistamine (azelastine) is now available. This is superior to either molecule used alone and offers more rapid onset of relief than INS alone, which takes up to two weeks to have maximal effect.3

Anti-leukotrienes
Montelukast has some efficacy in hayfever, similar to that of antihistamine. It can be used as an add-on in patients with concomitant asthma if control is poor.

Pressurised carbon dioxide
Trials have shown that application of carbon dioxide to each nostril for 10 seconds can reduce hayfever symptoms within minutes.4 Pressurised containers are available without prescription as rescue devices.

Oral corticosteroids
A brief course of prednisolone (for example, 0.5mg per kg orally in the morning for five days) can be used as rescue to reduce severe symptoms, but this should be accompanied by continued local nasal therapy. Depot injection corticosteroid preparations have an adverse risk/benefit profile and are not recommended, especially not as early season preventative treatment because the timing of release is inappropriate.

Intranasal decongestants
Topical decongestant formulations cause vasoconstriction and relieve obstruction within minutes, faster and more effectively than INS. For this reason, they are popular with patients. Unfortunately repeated use leads to tachyphylaxis and they are best avoided, or used only occasionally for brief periods of a few days. A combination spray with INS is available in the USA, but not yet in the UK.

Alternative remedies
The herb butterbur was shown to be as effective as an antihistamine in one study. However, herbal preparations are not often produced to good clinical practice standards and have been associated with liver disease so should not be encouraged.

Homeopathic preparations and acupuncture also have a weak evidence base.

Immunotherapy
Unlike pharmacotherapy, immunotherapy can alter the course of disease and there is evidence for a reduction in asthma and new sensitisations in patients given allergen-specific immunotherapy.

Sub-lingual dissolvable tablets of grass pollen allergen are available and are effective. They only require one visit for initial dosing, after which they are taken regularly at home. Subcutaneous regimes vary, some require four to six pre-seasonal injections, others – which appear more effective – involve year-round immunisation, initially weekly, then monthly.

All forms of immunotherapy require referral, usually to an allergist or immunologist for assessment of suitability for treatment. Patients with uncontrolled hayfever, despite concordance with pharmacotherapy, are prime candidates for referral. Also consider referring patients who cannot tolerate pharmacotherapy or whose futures may be impaired by their symptoms, such as teenagers who face years of important examinations in June.

Recent advances

The World Health Organization Allergic Rhinitis and its Impact on Asthma (ARIA) initiative began in 1999.5 The initial goals were to propose a new allergic rhinitis classification, to promote the concept of a link with asthma and to develop globally applicable guidelines.

ARIA now aims to provide an active and healthy life to rhinitis sufferers using emerging technologies for individualised care. An app (Android and iOS) has been developed using a visual analogue scale to assess symptom control and work productivity, and a clinical decision support system.6


Section 4: Prognosis

The cessation of hayfever can occur spontaneously, but this is unusual and many patients progress from grass pollen allergy to other sensitisations and to perennial rhinitis. Patients with hayfever have a threefold risk of developing asthma compared with those who do not have hayfever.


Section 5: Case study

Stephen is a 10-year-old boy with a five year history of hayfever. He has been treated with chlorphenamine as needed in response to symptoms. He likes to play football in the park after school but sometimes felt wheezy so used a salbutamol inhaler as rescue.

On a thundery evening in June Stephen was playing football in the park, despite having a cold, when he had an unexpected life-threatening asthma attack. Fortunately he was rapidly taken to hospital and recovered. The combination of a viral cold, allergen sensitisation and exposure to allergen carries an almost 20 fold risk of hospitalisation in children with asthma.

On review, it was considered that Stephen’s hayfever had not been adequately treated. Sedating antihistamines should not have been used. Because Stephen’s symptoms were present most days and were reducing his quality of life he was prescribed a regular intranasal corticosteroid, starting pre-seasonally. He was also using his salbutamol inhaler on most days, so was given a regular asthma preventer.

Stephen and his parents were warned that grass pollen levels rise in the evening so in future he should stay out of the park at that time of day. In thundery conditions small fragments of pollen can form and can penetrate to the lungs,7 so Stephen should remain indoors during thunderstorms.

Even when taking regular corticosteroids, Stephen continued to be symptomatic. His nasal therapy was increased to a combination nasal spray with both corticosteroid and antihistamine which gave good control of his hayfever and asthma. However, Stephen’s parents reported that his school work was suffering each summer and asked for a referral to an allergist.

Stephen was found to be monosensitised to grass pollen and immunotherapy was suggested. Sublingual tablet immunotherapy was chosen and an appointment was made for the first dose to be given under supervision.

At this appointment, Stephen was checked for rhinitis and asthma. His chest was clear and spirometry was normal, he had no oral lesions and the first tablet was placed under his tongue with instruction to keep it there as long as possible. He complained of mild itching in his mouth and throat. Subsequent doses were taken each morning at home. The oral itching decreased each day and stopped after two weeks.

During the next hay fever season Stephen was encouraged to use his nasal spray each day and to monitor his peak flow. There were no days of severe symptoms, no asthma and his school performance improved.

Stephen will repeat seven months of grass pollen tablet immunotherapy from January to July for the next two years. Evidence suggests that this should be enough to keep his hayfever and asthma controlled.


Section 6: Evidence base

Guidelines

Online resources

Dr Glenis Scadding is honorary consultant physician in allergy and rhinology, Royal National Throat, Nose and Ear Hospital, London

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References

  1. Clatworthy J, Price D, Ryan D et al. The value of self-report assessment of adherence, rhinitis and smoking in relation to asthma control. Prim Care Respir J 2009; 18(4): 300-5.
  2. Scadding GK, Durham SR, Mirakian R et al. BSACI guidelines for the management of rhinosinusitis and nasal polyposis. Clin Exp Allergy 2008; 38(2): 260-75.
  3. Meltzer EO, LaForce C, Ratner P et al. MP29-02 (a novel intranasal formulation of azelastine hydrochloride and fluticasone propionate) in the treatment of seasonal allergic rhinitis: a randomized, double-blind, placebo-controlled trial of efficacy and safety. Allergy Asthma Proc 2012; 33(4): 324-32
  4. Casale TB, Romero FA, Spierings EL. Intranasal noninhaled carbon dioxide for the symptomatic treatment of seasonal allergic rhinitis. J Allergy Clin Immunol 2008; 121(1): 105-9.
  5. Bousquet J, Van CP, Khaltaev N. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol 2001; 108(5 Suppl): S147-S334.
  6. Bousquet J, Hellings PW, Agache I et al. ARIA 2016: Care pathways implementing emerging technologies for predictive medicine in rhinitis and asthma across the life cycle. Clin Transl Allergy 2016; 6:47 DOI 10.1186/s13601-016-0137-4
  7. D’Amato G, Liccardi G, Fruengelli. Thunderstorm asthma and pollen allergy. Allergy 2007; 62: 11-16

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