Management of Hay Management of Hay Fever in primary careFever in primary care

Olusegun omosiniOlusegun omosini

ST2 GPVTSST2 GPVTS

EpidemiologyEpidemiology Allergic rhinitis significantly reduces quality of Allergic rhinitis significantly reduces quality of

life, interferes with both attendance and life, interferes with both attendance and performance at school and work and results in performance at school and work and results in substantial NHS costs. substantial NHS costs.

The prevalence of AR has increased over the last The prevalence of AR has increased over the last three decades three decades

Is common and affects over 20% of the UK Is common and affects over 20% of the UK populationpopulation

At most risk are those with hx of atopy, positive At most risk are those with hx of atopy, positive family history, first-born children and immigrantsfamily history, first-born children and immigrants

Closely associated with Asthma, Eczema and Closely associated with Asthma, Eczema and chronic sinusitischronic sinusitis

pathophysiologypathophysiology

AllergensAllergens

Types of Allergic RhinitisTypes of Allergic Rhinitis

Seasonal AR ( hay fever ) - tree Seasonal AR ( hay fever ) - tree pollen, grass, same time yearlypollen, grass, same time yearly

Perennial AR- house dust mite Perennial AR- house dust mite (HDM), pets, symptoms occur (HDM), pets, symptoms occur throughout yearthroughout year

Occupational AR- allergens at Occupational AR- allergens at workplace, e.g. latex gloves, flourworkplace, e.g. latex gloves, flour

classificationclassification

Diagnosis of AR - HxDiagnosis of AR - Hx Sneezing, itchy nose, itchy palate.Sneezing, itchy nose, itchy palate. Rhinorrhoea – bil, clear or yellowRhinorrhoea – bil, clear or yellow Nasal obstruction - bilateralNasal obstruction - bilateral Nasal crusting – uncommon, ?topical steroidsNasal crusting – uncommon, ?topical steroids Eye symptoms – resolve within 24hrs away from Eye symptoms – resolve within 24hrs away from

allergenallergen Other symptoms – snoring, sniffing, nasal Other symptoms – snoring, sniffing, nasal

intonation, hyposmiaintonation, hyposmia Lower respiratory tract symptomsLower respiratory tract symptoms Family history – hx of atopyFamily history – hx of atopy Social history – house, petsSocial history – house, pets Occupation.Occupation.

ExaminationExamination

Visual assessment – nasal salute, Visual assessment – nasal salute, nasal crease, rhinorrheanasal crease, rhinorrhea

Anterior rhinoscopy – secretions, Anterior rhinoscopy – secretions, polyps, crusting, septal perforationpolyps, crusting, septal perforation

InvestigationInvestigation

Allergen-specific IgEAllergen-specific IgE Skin prick tests – suppressed by Skin prick tests – suppressed by

antihistamines, topical corticosteroidsantihistamines, topical corticosteroids Serum total and specific IgE.Serum total and specific IgE. Routine laboratory investigations.Routine laboratory investigations. Olfactory tests.Olfactory tests. CytologyCytology Nasal challengeNasal challenge

General principles of managementGeneral principles of management

EducationEducation Allergen avoidanceAllergen avoidance HDM avoidanceHDM avoidance Pollen avoidance Pollen avoidance Cat allergenCat allergen Occupational allergens.Occupational allergens. Irritant avoidance.Irritant avoidance.

BSACI guidelines on mgtBSACI guidelines on mgt

Oral H1-antihistaminesOral H1-antihistamines

Reduce total nasal symptom scores by a mean of Reduce total nasal symptom scores by a mean of 7% (5–9%) more than placebo.7% (5–9%) more than placebo.

Effective predominantly on neurally mediated Effective predominantly on neurally mediated symptoms of itch, sneeze and rhinorrhoea.symptoms of itch, sneeze and rhinorrhoea.

Desloratadine, fexofenadine, satirizing and Desloratadine, fexofenadine, satirizing and levocetirizine have modest effects on nasal levocetirizine have modest effects on nasal blockage.blockage.

Improve allergic symptoms at sites other than the Improve allergic symptoms at sites other than the nose such as the conjunctiva, palate, skin and nose such as the conjunctiva, palate, skin and lower airways.lower airways.

Regular therapy is more effective than ‘as-Regular therapy is more effective than ‘as-needed’ use in persistent rhinitis.needed’ use in persistent rhinitis.

Can significantly improve QOL.Can significantly improve QOL.

topical (nasal) H1-antihistamines topical (nasal) H1-antihistamines

Therapeutic effects superior to oral Therapeutic effects superior to oral antihistamines for nasal rhinitis antihistamines for nasal rhinitis symptoms symptoms

Do not improve symptoms due to Do not improve symptoms due to histamine at other siteshistamine at other sites

Fast onset of action within 15 min – Fast onset of action within 15 min – useful as rescue therapy.useful as rescue therapy.

Useful for trx of mild persistent ARUseful for trx of mild persistent AR

Topical intranasal corticosteroidsTopical intranasal corticosteroids

Meta-analysis shows that intranasal corticosteroids Meta-analysis shows that intranasal corticosteroids are superior to antihistamines.are superior to antihistamines.

Act by suppression of inflammation at multiple points Act by suppression of inflammation at multiple points in the inflammatory cascade.in the inflammatory cascade.

Reduce all symptoms of rhinitis by about 17% greater Reduce all symptoms of rhinitis by about 17% greater than placebo, with a variable effect on conjunctivitisthan placebo, with a variable effect on conjunctivitis

Onset of action is 6–8 h after the first dose, clinical Onset of action is 6–8 h after the first dose, clinical improvement may not be apparent for a few days improvement may not be apparent for a few days and maximal effect may not be apparent until after and maximal effect may not be apparent until after 2wks.2wks.

Starting treatment 2 weeks before a known allergen Starting treatment 2 weeks before a known allergen season improves efficacy.season improves efficacy.

Similar clinical efficacy for all INSSimilar clinical efficacy for all INS Safe for long term use (?beclomethasone)Safe for long term use (?beclomethasone)

How to apply nose dropsHow to apply nose drops

Systemic steroidsSystemic steroids

Rarely indicated in the management of rhinitis, Rarely indicated in the management of rhinitis, except for:except for:

severe nasal obstructionsevere nasal obstruction short-term rescue medication for uncontrolled short-term rescue medication for uncontrolled

symptoms on conventional pharmacotherapysymptoms on conventional pharmacotherapy Important social or work-related eventsImportant social or work-related events Oral corticosteroids should be used briefly and Oral corticosteroids should be used briefly and

always in combination with a topical nasal always in combination with a topical nasal corticosteroid.corticosteroid.

A suggested regime for adults is 0.5 mg/kg given A suggested regime for adults is 0.5 mg/kg given orally in the morning with food for 5–10 days.orally in the morning with food for 5–10 days.

Injectable corticosteroidsInjectable corticosteroids

Anti-leukotrienesAnti-leukotrienes

Anti-leukotrienes are of two kinds: Anti-leukotrienes are of two kinds: (i) receptor antagonists LTRAs, (e.g. (i) receptor antagonists LTRAs, (e.g.

montelukast and zafirlukast)montelukast and zafirlukast) (ii) synthesis inhibitors, e.g. zileuton(ii) synthesis inhibitors, e.g. zileuton There is a spectrum of individual responsiveness There is a spectrum of individual responsiveness

to LTRAs that is currently not predictable.to LTRAs that is currently not predictable. A study found that LTRAs reduced the mean daily A study found that LTRAs reduced the mean daily

rhinitis symptom scores by 5% more than placeborhinitis symptom scores by 5% more than placebo Therapeutic profile similar to antihistamines, with Therapeutic profile similar to antihistamines, with

efficacy comparable to loratadine in .However, efficacy comparable to loratadine in .However, the response is less consistent than that observed the response is less consistent than that observed with antihistamines.with antihistamines.

Anti-leukotrienes are less effective than topical Anti-leukotrienes are less effective than topical nasal corticosteroids.nasal corticosteroids.

Topical anti-cholinergicTopical anti-cholinergic

ipratropium bromide (Rinatecs)ipratropium bromide (Rinatecs) Decreases rhinorrhoea but has no Decreases rhinorrhoea but has no

effect on other nasal symptoms.effect on other nasal symptoms. Needs to be used three times dailyNeeds to be used three times daily Useful in common coldUseful in common cold

Intranasal decongestantsIntranasal decongestants

. The a1-agonist ephedrine and a2-. The a1-agonist ephedrine and a2-agonist xylometazoline agonist xylometazoline

They are sympathomimetics that They are sympathomimetics that increase nasal vasoconstrictionincrease nasal vasoconstriction

Effective for nasal obstruction.Effective for nasal obstruction. Brief use of < 10 days to avoid Brief use of < 10 days to avoid

rebound effectrebound effect Causes nasal irritationCauses nasal irritation May increase rhinorrheaMay increase rhinorrhea

ChromonesChromones Sodium cromoglicate and nedocromil sodium Sodium cromoglicate and nedocromil sodium

inhibit the degranulation of sensitized mast cells,inhibit the degranulation of sensitized mast cells, some effect on nasal obstruction.some effect on nasal obstruction. The spray needs to be used several times 3-4 The spray needs to be used several times 3-4

times per daytimes per day Causes local irritationCauses local irritation Rarely transient bronchospasmRarely transient bronchospasm Occasional taste perversionOccasional taste perversion HeadacheHeadache Well tolerated in pregnancy and in children with Well tolerated in pregnancy and in children with

mld symptomsmld symptoms Very useful for eye symptomsVery useful for eye symptoms

Allergen immunotherapyAllergen immunotherapy

Repeated administration of an allergen extract inRepeated administration of an allergen extract in Reduces symptoms and the need for rescue Reduces symptoms and the need for rescue

medication on subsequent exposure to that allergenmedication on subsequent exposure to that allergen Immunotherapy can be highly effective and is the Immunotherapy can be highly effective and is the

only treatment that is able to modify the natural only treatment that is able to modify the natural history of AR and offer the potential for long-term history of AR and offer the potential for long-term disease remissiondisease remission

Immunotherapy is recommended in those subjects Immunotherapy is recommended in those subjects with IgE-mediated disease in whom allergen with IgE-mediated disease in whom allergen avoidance is either undesirable or not feasible and avoidance is either undesirable or not feasible and who fail to respond to optimal treatment.who fail to respond to optimal treatment.

Sublingual immunotherapy (SLIT) has been proposed Sublingual immunotherapy (SLIT) has been proposed as an alternative to the subcutaneous route.as an alternative to the subcutaneous route.

SurgerySurgery

Drug-resistant inferior turbinate Drug-resistant inferior turbinate hypertrophy.hypertrophy.

Anatomical variations of the septum Anatomical variations of the septum with functional relevance.with functional relevance.

Anatomical variations of the bony Anatomical variations of the bony pyramid with functional relevance.pyramid with functional relevance.