Managing allergic rhinitis

How to treat seasonal exacerbations in primary care. By Dr Suneeta Kochhar

Allergic rhinitis is characterised by sneezing and itching (Photograph: JH Lancy)
Allergic rhinitis is characterised by sneezing and itching (Photograph: JH Lancy)

Rhinitis is a common problem affecting approximately 24% of the UK adult population. There is a peak incidence in childhood and adolescence.

It refers to inflammation of the nasal membranes; associated symptoms include sneezing, nasal congestion, nasal itching and rhinorrhoea.

Rhinitis may be subdivided into allergic rhinitis (AR) and non-allergic rhinitis (non-AR).

The symptomatology is similar, but AR is characterised by sneezing and itching, whereas the most common symptoms in non-AR are nasal blockage and rhinorrhoea.

1. Causes and risk factors

AR is due to an IgE-mediated inflammation of the membranes lining the nose caused by allergen exposure; this is the most common cause of rhinitis. Symptoms may significantly limit activities of daily living and cause significant morbidity. Both AR and non-AR are risk factors for the development of asthma. Wegener's granulomatosis, sarcoidosis and Churg-Strauss syndrome may present with rhinosinusitis.

Non-AR may be inflammatory as well as non-inflammatory. Infective rhinitis can be caused by a self-limiting viral infection.

AR can be seasonal (hayfever), perennial (persistent) or perennial with seasonal exacerbations. It can often be diagnosed from the clinical history.

It is vital to establish whether there is a relationship between allergen exposure and symptoms. This may be difficult if there is persistent exposure, for example, to house dust mites.

Holiday time remission suggests an environmental cause. Occupation, previous history of allergy and family history are relevant in taking a history to establish AR.

Treatment of AR is rarely allergen-specific, so diagnostic tests are often not required but may be helpful if suitability for immunotherapy needs to be assessed. Diagnostic tests may be used to identify an avoidable trigger. Allergen avoidance may be a helpful management option in primary care.

2. Management options

Oral and topical antihistamines are first-line therapies for mild to moderate intermittent and mild persistent rhinitis.

They may also be used in addition to intranasal steroids for moderate to severe persistent rhinitis. Oral H1-antihistamines are effective predominantly for itch, sneeze and rhinorrhoea.

Regular therapy is more effective than 'as-needed' use in persistent rhinitis. Topical nasal H1-antihistamines, such as azelastine, may have a greater effect than oral antihistamines for rhinitis symptoms.

In mainland Europe, nasal douching is a more commonly used therapy in children and adults than in the UK. This may be used first-line.

Topical nasal corticosteroids are the treatment of choice for moderate to severe disease. Treatment failure may be related to poor technique in the use of nasal sprays and drops. Long-term growth studies in children using fluticasone, mometasone and budesonide have reassuring safety data.

Beclomethasone should not be used in children. It is advisable to monitor growth in children. Topical steroid drops should be used initially in nasal polyposis and severe obstruction.

Systemic glucocorticosteroids are rarely indicated but sometimes short courses of prednisolone may be given depending on circumstances; however, there is little evidence for this practice. Injected preparations are not recommended. Leukotriene receptor antagonists are less effective than topical nasal corticosteroids.

Montelukast is licensed in the UK for those with seasonal AR who also have concomitant asthma; therefore it may be helpful in patients with asthma and persistent rhinitis.

Topical anticholinergics, such as ipratropium bromide, decrease rhinorrhoea but have no effect on other nasal symptoms. Intranasal decongestants are sympathomimetics that increase nasal vasoconstriction. If they are used it is advisable to avoid prolonged use due to the risk of rebound effect.

Key points
  • AR is characterised by sneezing and itching, whereas the most common symptoms in non-AR are nasal blockage and rhinorrhoea.
  • AR can be seasonal (hayfever), perennial (persistent) or perennial with seasonal exacerbations.
  • Allergen avoidance should be discussed.
  • Pharmacological management depends on predominant symptoms and severity.

Sodium cromoglicate and nedocromil sodium inhibit the degranulation of sensitised mast cells, inhibiting the release of inflammatory and allergic mediators. Sodium cromoglicate is modestly effective in rhinitis but has some effect on nasal obstruction symptoms.

For those with residual symptoms on a maximum licensed dose of intranasal corticosteroid, it is recommended that the treatment is continued and addition of an oral antihistamine and/or intranasal ipratropium is considered.

Immunotherapy
Grass pollen immunotherapy or desensitisation is useful in patients who are unresponsive to, or cannot tolerate, pharmacotherapy. Subcutaneous immunotherapy has been shown to reduce symptoms and medication use; moreover, long-term efficacy of immunotherapy injections following three years of treatment has been demonstrated. Sublingual tablets are available as a once-daily treatment for grass pollen induced allergic rhinoconjunctivitis.

3. Allergic rhinitis in children

Antihistamines are useful in AR if the main symptoms are rhinorrhoea and sneezing. Desloratadine, cetirizine and fexofenadine may be beneficial for symptoms of nasal congestion. Nasal steroids with low systemic bioavailability should be used at the lowest possible dose to control symptoms and are useful for nasal congestion and obstruction.

Leukotriene receptor antagonists may have a role if there is allergic rhinitis and concomitant asthma.

4. Follow-up

Patients should be advised to reattend after two to four weeks if their symptoms remain inadequately controlled. The main reasons for treatment failure will be poor compliance, poor nasal spray technique, inadequate dosing or continued exposure to a relevant allergen.

Follow-up is vital if symptomatic control is suboptimal, because AR can have a significant effect on quality of life.

  • Dr Kochhar is a GP principal in St Leonards, East Sussex

Reflect on this article and add notes to your CPD organiser on MIMS Learning

References
1. Costa DJ, Bousquet PJ, Ryan D et al. Prim Care Respir J 2009; 18(4): 250-7.

2. Walker SM, Durham SR, Till SJ et al. Clin Exper Allergy 2011; 41: 1177-200.

3. Scadding GK, Durham SR, Mirakian R et al. Clin Exper Allergy 2008; 38: 19-42.

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