Rhinitis is a condition where inflammation of the nasal mucosa leads to a set of characteristic symptoms (see Table 1) that may vary in timing and severity. When a patient has ocular in addition to nasal symptoms the condition is called rhino-conjunctivitis. Around 10-15% of children and 26% of adults in the UK experience rhinitis, and rhinitis is strongly associated with asthma (Scadding et al, 2017). Rhinitis can be allergic or non-allergic, with the allergic form being more common at an estimated ratio of 3:1 (Scadding et al, 2017). Allergic rhinitis can be troublesome all year round (perennial allergic rhinitis) or at certain times of the year depending on the causative allergen (seasonal allergic rhinitis – hay fever). People can suffer with one or both forms of allergic rhinitis meaning that they could experience symptoms virtually all year round. Allergic rhinitis is classified according to symptom frequency and severity, ranging from mild to severe and intermittent to persistent (Scadding et al, 2017).
Table 1. Hay fever symptoms
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Impact of allergic rhinitis
Allergic rhinitis symptoms that are not controlled lead to adverse effects that significantly impact quality of life; these include headache, sore throat, hearing problems, sleep disturbance, poor concentration and behaviour alterations (Scadding et al, 2017). Furthermore, a detrimental impact on school attendance, productivity and performance in adolescents is well-reported (Walker et al, 2007; Blaiss et al, 2018). The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines developed the now widely used framework for classifying allergic rhinitis (see Figure 1); it is this framework that enables health professionals to assess patients and guide management decisions.
Figure 1. Allergic Rhinitis and its Impact on Asthma (ARIA) classification.
Allergic rhinitis and asthma
Rhinitis, in all its forms, is a risk factor for the development of asthma, and rhinitis also adversely affects asthma control (Scadding et al, 2017). Allergic rhinitis is a common asthma comorbidity in both adults and children (Kaplan et al, 2020), affecting as many as 81% of people with asthma (Scadding et al, 2017). Allergy management is integral to and synonymous with asthma management in terms of optimising asthma control and maintaining patient safety. The National Review of Asthma Deaths (NRAD) found that there are allergic links to child asthma deaths and that most children in the audit period died during the summer months (Royal College of Physicians, 2014). The CARAT (Control of Asthma and Allergic Rhinitis) test is a validated tool that can be used to assess disease control and guide clinical decision making (see http://www.caratnetwork.org/). In their paper discussing the application of the CARAT tool in primary care, Azevedo et al (2013) suggest that use of the tool can empower patients to better self-management of their asthma and allergy, and strengthen patient–professional relationships, thus reducing risk and improving quality of life. It is important to include allergy assessment and management in routine asthma care and to consider the principles of ‘one airway, one disease’, whereby joint management of both asthma and allergic rhinitis leads to better overall disease control (Giavina-Bianchi et al, 2016).
Hay fever seasons
Hay fever is seasonal because plants pollens are dispersed during the plant's growing season and the allergic reaction to specific pollens occurs only when dispersal is taking place. Pollen dispersal occurs during dry weather and even when air pollen levels are low, people who are highly sensitive can still be affected (Bartle et al, 2017). The growing season for plants occurs at approximately the same time every year and knowledge of this helps with planning and implementing management strategies. Plant pollen categories in the UK include tree, grass, weed pollen and mould spores (see Table 2).
Table 2. Plant pollen categories in the UK and their seasons
| Allergen | Season |
|---|---|
| Tree pollen | March–April |
| Grass pollen | May–July |
| Weed pollen | June–August |
| Mould spores | September–October |
Perennial allergic rhinitis
Common allergens include house dust mite, indoor mould and pet dander; persistent exposure leads to an ongoing late-phase inflammatory response characterised by nasal obstruction.
Managing allergic rhinitis
Allergic rhinitis can be difficult to manage and achieving effective symptom control usually requires a multifactorial approach. Patients who have a poor perception of allergic rhinitis delay seeking medical advice; for up to 7 years after the onset of the disease according to Demoly et al (2020). Patient perceptions about trigger/allergen avoidance and effectiveness of medications varies, with over 90% of patients in one study believing prescription medication to be more effective than that available over the counter (Demoly et al, 2020). Further, patients do not follow recommendations or adhere to treatment, and they treat themselves according to their perception of their symptoms (Klimeck et al, 2019).
Poor patient perceptions and related impact on their behaviour around self-management of their health is well reported in all chronic diseases and often a source of frustration for health professionals. However, what it does tell us is that patients make decisions about how to manage their health all of the time; patient beliefs, preferences and patient choice are fundamental elements of high-quality care, therefore personalised approaches are essential (NHS England, 2021).
The NHS Long Term Plan has committed to person-centred care, to supporting people to manage their own health, and to a digital-first health service (NHS England, 2019). We need to think about how these drivers can work for people with allergic rhinitis.
Non-pharmacological and pharmacological strategies all have a role to play in managing allergic rhinitis and a combination will be needed to achieve effective disease control for most patients.
Non-pharmacological management
Allergen avoidance can be extremely effective; however, many allergens are difficult to avoid. Hay fever, for example, only occurs when the pollen is being dispersed; unfortunately, complete avoidance of pollen is virtually impossible. Reduction strategies such as staying indoors and keeping windows shut when pollen counts are high are helpful for some, but for many these avoidance tactics are impractical and unrealistic. Other strategies such as wearing sunglasses and applying ointment to the nose when outdoors may be helpful (Scadding et al, 2017).
House dust mite avoidance is impossible, but some people may be keen to try reduction strategies and there is some, albeit limited, evidence to suggest effectiveness in improving control of both asthma and allergic rhinitis (Scadding et al, 2017; British Thoracic Society [BTS]/Scottish Intercollegiate Guidelines Network [SIGN], 2019). Current British asthma guidelines do not routinely recommend house dust mite reduction strategies, but do advise that in people wanting to try it, multiple strategies are likely to be most effective (BTS/SIGN, 2019). For example, combining good ventilation, encasing mattresses and pillows, damp dusting, hard flooring, soft furnishing elimination and filtered vacuum cleaning will derive more benefit than a single measure.
In cases of animal dander allergy where exposure leads to an immediate allergic response, complete avoidance is advised, and in cases where an individual is sensitised to their pet there is no firm evidence that reduction strategies such as washing the pet are effective (Scadding et al, 2017).
Saline irrigation of the nasal passages reduces symptoms and may reduce the level of pharmacological treatment required; a Cochrane review found the method is easy to use, inexpensive and well tolerated by adults and children (Head et al, 2018). This non-pharmacological management strategy is widely used across Europe and is becoming increasingly used in the UK.
Courses
- Asthma Foundation Course: https://rotherhamrespiratory.com/
- Allergy Academy: http://www.allergyacademy.org/home
Resources
- Allergy UK: https://www.allergyuk.org/
- British Society of Allergy and Clinical Immunology: https://www.bsaci.org/
- Asthma UK: https://www.asthma.org.uk/
Pharmacological management
Current guidelines recommend a stepwise approach to pharmacological management (Figure 2) based on the classification of disease severity set out in Figure 1 (Scadding et al 2017).
Figure 2. BSACI Allergic Rhinitis Guidelines. Scadding et al, 2017. INS, intranasal corticosteroids; LTRA, leukotriene receptor antagonists
Antihistamines are recommended as first-line therapy for mild–moderate intermittent allergic rhinitis and for mild persistent allergic rhinitis (Scadding et al, 2017). Oral, intranasal and ocular formulations are available and are most helpful for sneezing, runny nose and itching; they are less effective for nasal obstruction. Non-sedating antihistamines are preferred to avoid adverse effects of somnolence (drowsiness) (Bartle et al, 2017) and these are widely available over-the-counter in shops, supermarkets and community pharmacies.
Intranasal steroids are the most effective and appropriate treatment for persistent nasal allergy symptoms, particularly nasal blockage (Scadding et al, 2017). They reduce nasal inflammation and hypersensitivity. However, treatment failure is common, usually due to poor concordance and poor technique (see Box 1 for tips when teaching patients to use intranasal steroids). All intranasal steroids are effective, but drug bioavailability varies; systemic bioavailability is lowest with mometasone and fluticasone (Scadding et al, 2017) – an important consideration for patients taking other steroids, eg for asthma and/or eczema.
Box 1.Simple intranasal spray technique
- Blow nose, shake the bottle and remove the cap
- Look towards the floor
- Using the right hand insert the nasal spray just inside the left nostril and spray once – breathe in or sniff very gently
- Repeat using the left hand to insert the spray in the right nostril
- Dab any drips away – do not blow nose
Remember the purpose of treatment is to wet the lining of the nose with the nasal sprayAdverse effects such as unpleasant sensation at the bridge of the nose or a nasty taste in the mouth indicate poor techniqueIntranasal steroids need to be taken daily and may take up to 2 weeks to be fully effective
Patients may need a combination of antihistamine and intranasal steroids to control their symptoms; this combination is the mainstay of treatment for many patients. Additional options if control is difficult to achieve include (see Figure 2) (Scadding et al, 2017):
- Ipratropium nasal spray
- Antileukotrienes
- Oral steroids
- Referral for surgery or immunotherapy.
Conclusion
Allergic rhinitis places a considerable burden on patients, affecting their health, well-being and quality of life. Yet many people with allergic rhinitis delay seeking professional advice, often choosing to self-care instead. Therefore, sources of high-quality information and support must be readily available. Practice websites and the local pharmacy are the ideal place for patients to access information. Signposting to reputable sources such as the NHS and Allergy UK websites is a good starting point. The CARAT tool, which is available both in hard copy and electronically, is a helpful resource to use with patients who have both asthma and allergic rhinitis. Health professionals may capture people with allergic rhinitis opportunistically, eg in the pharmacy or during asthma reviews. Such opportunities enable health professionals to talk to people about their allergy symptoms and support their self-management with education and advice. Non-pharmacological and pharmacological strategies combine to form the overall approach to managing allergic rhinitis and health professionals with knowledge and understanding of these are well placed to support patients and deliver improved outcomes.
CPD reflective practice:
- Reflecting on your practice, could you do more to help ensure your asthma patients manage any allergic rhinitis symptoms? Why is this important?
- Why is a combination of pharmacological and non-pharmacological management needed for effective control of symptoms for most people?
- How could you help to reduce treatment failure in your patients?
Key Points
- Allergic rhinitis is a common disease that places considerable burden on patients
- Health professionals have an important role in supporting patients to self-manage their condition
- The basis of management is a combination of non-pharmacological and pharmacological strategies