In this article we consider the importance of making a diagnosis of allergic rhinitis and determine the severity of symptoms so that appropriate treatment strategies and ongoing management can be implemented.
By the end of this article, readers should be able to:
- Recognise the features that support a diagnosis of AR.
- Identify the relationship between asthma and AR.
- Consider how visual analogue scales and other tools can identify the impact that AR is having on the individual.
- Reflect on non-pharmacological interventions that can support improved quality of life.
- Determine the evidence-based approach to the pharmacological management of AR, with and without asthma.
Key features which support a diagnosis of allergic rhinitis
Allergic rhinitis (AR) is a condition which affects the nasal mucosa and, in some cases, other organs including the eyes, palate, and lungs (Hossenbaccus et al 2020). The condition results from an IgE-mediated reaction to airborne allergens (Bantz, Zhu & Zheng 2014). These allergens vary throughout the year and from person to person and might include pollen, moulds, house dust mite and animals. People with seasonal allergic rhinitis (SAR) will develop symptoms when they are exposed to a specific seasonal allergen (or allergens). Other people will experience year-round symptoms and are said to have perennial AR (PAR). SAR is a key cause of an increase in asthma symptoms, exacerbations and deaths, especially in children and young people (Royal College of Physicians 2014, D’Amato et al 2016).
AR is part of the atopic spectrum of conditions which also includes asthma, nasal polyps, food allergy and eczema (Cingi et al 2017). AR can present as a mild condition but can also be a cause of significant morbidity, impacting on sleep, work life or schooling (Wise et al 2018).
The international EUFOREA Allergic Rhinitis guideline recommends that the diagnosis can be made through the presence of two or more symptoms, occurring for at least one hour on most days when related to allergen exposure. These symptoms include a runny nose, sneezing, nasal obstruction, nasal itch and eye symptoms (itch, redness or tearing) (EUFOREA 2021). The confirmation of an allergic basis for the symptoms can be made using objective tests, which might include an immunoglobulin E (IgE) blood test and positive skin prick testing for suspected allergens (Testera-Montes et al 2021).
The link between asthma and AR
Asthma and allergic rhinitis are part of the atopic spectrum and affect the same airway. Around 10-40% of people with AR have asthma while between 6-85% of people with asthma have nasal symptoms (Brozek et al 2017, Global Initiative for Asthma [GINA] 2022). Despite the close relationship between asthma and AR, clinicians and patients can often miss AR as a cause of uncontrolled or worsening asthma symptoms. The possibility of AR should therefore be assessed in the asthma review by asking about symptoms, triggers and seasonal variation (British Thoracic Society/Scottish Intercollegiate Guidelines Network [BTS/SIGN] 2019). People with AR should be assessed for comorbid asthma. Symptoms which might suggest asthma include episodes of wheeze, nocturnal or exercise-induced cough or wheeze, a tight chest or other recurrent respiratory symptoms (BTS/SIGN 2019, Levy et al 2023).
Using tools to support clinicians and patients.
In AR it is important to consider both the presence of symptoms and the severity, in order to determine the level of morbidity and the impact of treatments. The use of a visual analogue scale (VAS) can help to determine this. The AR VAS uses a scale from 0–10, 0 suggesting that the symptoms are not present or bothersome at all and 10 indicating that they are extremely bothersome (Klimek et al 2017). A score of 5 or more would indicate that AR symptoms are uncontrolled, and the aim would be to get the score to below 5, i.e., controlled AR. The lower the score, the better the symptom control. The scale can be used before, during and after treatment initiation and will ensure that the management of the condition is fine-tuned for each individual.
The MASK-air app has been designed to enable people living with AR to record and monitor their symptoms in order to manage them more effectively with the ultimate aim of improving quality of life. The ARIA-MASK-air app is for people with asthma and coexisting AR (Bousquet et al 2023). Other assessment tools are available for AR, including the total nasal symptom score (TNSS).
Non pharmacological management of AR
The management of AR should include pharmacological and non-pharmacological approaches. Avoidance of allergens is recommended, which may be achieved in part by staying indoors, and keeping doors and windows closed. Pollen counts tend to be highest in the early morning and early evening, so minimising time outdoors at these times, if possible, may help to reduce the impact of aeroallergens (EUFOREA 2021).
Saline nasal douching can help in very mild cases of AR and post-nasal drip and this approach has a very low risk of side effects and interactions (Head et al 2018). Some people may find a nasal barrier cream useful.
Pharmacological management of AR
Most people with AR benefit from an oral antihistamine (non-drowsy where possible, depending on age) and/or an intranasal steroid; intranasal antihistamines can be more effective than oral and, in some cases, a combined intranasal steroid (INS) and intranasal antihistamine will be preferred to achieve the necessary level of symptom control (Hellings et al 2020). As with asthma inhalers, correct technique is essential and the Asthma and Lung UK website has a video on this subject which can be shared with patients and carers: https://www.asthmaandlung.org.uk/living-with/inhaler-videos/nasal-spray
Ideally treatment should be started around 2–4 weeks before the individual's usual AR season begins. Patients should be advised that although they may get some relief from an INS quite quickly (around 6–8 hours for some therapies) treatment effects will be optimised at around 2 weeks, which is why a review around this time is useful (EUFOREA 2021). If using an intranasal antihistamine such as azelastine, with or without an INS, the effect can be felt within 15–30 minutes (Patel et al 2020). People with allergic conjunctivitis may also benefit from eye drops (Dupuis et al 2020). As AR is part of the atopic spectrum, it is important to consider the steroid load of someone who may be using inhaled, intranasal and topical steroids. INS treatments with low bioavailability (fluticasone propionate, fluticasone furoate or mometasone furoate) should be selected where possible.
At the first review, the VAS should be repeated along with an assessment of current symptoms. Based on the response, the decision may be taken to reduce, maintain or increase medication. If symptoms persist and the VAS score is still 8–10, referral to an Ear, Nose, Throat or allergy specialist should be considered. The clinician should check that current medication is being taken as prescribed, using the correct technique, before specialist intervention is sought to determine the next steps. In some cases, ipratropium, allergen immunotherapy (desensitisation), oral corticosteroids or even surgery may be indicated.
Allergen immunotherapy (AIT) can be used in AR, rhinoconjunctivitis or allergic asthma and has been shown to be effective in reducing symptoms (Boonpiyathad et al 2021). It is administered subcutaneously (SCIT) or sublingually (SLIT). If successful, AIT can reduce the need for other medication.
Treating asthma and AR
People with asthma who also suffer from AR can be prescribed a leukotriene receptor antagonist (LTRA) such as montelukast which, when used with an inhaled corticosteroid, can effectively treat both the asthma and the AR (BTS/SIGN 2019, Zuberi et al 2020). Montelukast is licensed for use from age 6 months and above, but prescribers should be mindful of the increased risk of neuropsychiatric side effects (Paljarvi et al 2022). The Medicines and Healthcare Products Regulatory Agency (MHRA) has issued a warning to this effect (MHRA 2019)
The GINA guidelines recommend that in people with seasonal asthma and no interval symptoms outside of their season, an inhaled ICS should be started at the onset of symptoms and continued for four weeks after their relevant pollen season ends (GINA 2022). However, GINA also suggests that an ‘as required’ ICS/formoterol combination can be prescribed in order to offer symptom relief while concurrently treating the underlying inflammation. At the time of writing only Symbicort Turbohaler™ 200/6 mcg is licensed to be used this way, and only for people aged 12 and above. GINA also recommends prn ICS/formoterol in mild, non-seasonal asthma.
If people opt to use their inhaler on a prn basis or only for the part of the year when AR causes asthma symptoms, their personalised asthma action plan (PAAP) should reflect this and should include a reminder about triggers and trigger avoidance.
In spring and summer, airborne allergens such as pollens and spores and poor air quality can lead to an increase in AR and asthma symptoms (Takemura et al 2016, Yu et al 2020). Thunderstorms can also lead to increases in the concentration and dispersal of aeroallergens, particularly tree pollens, resulting in thunderstorm-associated asthma (D’Amato et al 2021). People with asthma and pollenrelated AR are most at risk from thunderstorm-triggered exacerbations. However, good adherence to preventer medication resulted in a decreased risk of thunderstorm-triggered exacerbations (Chatelier et al 2021).
Autumnal spikes in asthma attacks, particularly in children returning to school, may also be related to a rise in aeroallergens and viruses, although this rise is not seen when children return to school after other school holiday periods (Satia et al 2020).
It is essential then that people living with asthma and AR know to start and adjust their treatment to optimise symptom control and reduce the risk of exacerbations. They should be advised to consider an increase in symptoms as being abnormal and unacceptable.
Summary
AR is a condition which is part of the atopic spectrum. Some people may suffer from AR alone while others may have coexisting asthma, which may or may not have been diagnosed. History taking to identify symptoms of these conditions is key, but the use of objective tests and visual analogue scales can help to support the diagnosis and ongoing management. People should be aware of the role of allergens in AR and asthma and should know their triggers. Advice should be given about allergen avoidance and the place for pharmacological interventions, which may include oral antihistamines, and intranasal steroids, with or without intranasal antihistamines for AR and inhaled corticosteroids with a long-acting beta2 agonist and/or an LTRA for asthma. If the use of a combination nasal spray has failed to control the symptoms of AR and adherence and technique are good, referral should be considered. Allergen immunotherapy may help to control symptoms and reduce the need for other medication. The use of a symptom diary, including the MASK-air app, will help the person with AR and the clinician to work together to decide the best course of action.