Seasonal allergic rhinitis (SAR),

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1 How to identify and manage seasonal allergic rhinitis Dermot Ryan Allergic rhinitis (AR) is a common disorder which has a major impact on the lives of sufferers and families. Although currently there is no cure for this disease, a variety of therapeutic interventions can alleviate the. It is important that nurses are able to differentiate allergic and non-allergic rhinitis (NAR) from viral upper respiratory tract infections (URTIs) in order to best manage their patients. It is also necessary to ask appropriate questions of those patients attending for asthma review, as they may have unrecognised and untreated disease. Familiarity with the range of medications and their administration is advocated. Patients with troublesome, non-responding need to be referred, as do those with red flag signs. KEYWORDS: Respiration Rhinitis Quality of life Symptoms Seasonal allergic rhinitis (SAR), more frequently referred to as hay fever, is a common disorder suffered by a great many people in the United Kingdom. It is often referred to by patients as a summer cold, which lasts a long time and will not go away. Since its first identification in 1819 by John Bostock, a physician from Manchester, there has been a progressive global increase of both prevalence and severity of seasonal allergic rhinitis (Bousquet et al, 2008). Clinicians are familiar with the person who comes in at the end of May or beginning of June with itching, sneezing and a runny or blocked nose, often accompanied by itchy and teary eyes and sometimes also with cough and wheeze. What Dermot Ryan, honorary clinical research fellow, University of Edinburgh; chair, Primary Care Interest Group, European Academy of Allergy and Clinical Immunology many do not realise is that there are many hay fever, or properly, pollen, seasons throughout the year. However, the pollen which receives the greatest attention occurs typically in late spring and early summer. Although the main culprit is grass pollen, there are an increasing number of aeroallergens, such as birch, hazel, nettle and latterly even ragweed, which are now causing over a longer time frame. The appropriate name is now allergic rhinitis (AR). Some people have more than one seasonal allergen and thus may have multiple bouts throughout the year (Figure 1). It is also a common feature that patients suffer badly in some years, while in others not at all. such as ground-level ozone. Finally, circumstances in the patient s life may influence the season-toseason variability, such as smoking, intercurrent illness or stress. DIAGNOSING SEASONAL ALLERGIC RHINITIS In straightforward SAR/ AR the diagnosis is relatively simple. The patient complains of runny nose, sneezing, itching (of nose, palate, ears) and nasal blocking, frequently accompanied by eye of itching and tearing (allergic conjunctivitis). Equally common is the patient presenting with a summer cold a runny or blocked nose which has persisted for a couple of weeks. It is important to differentiate allergic from non-allergic rhinitis (NAR), especially as NAR responds poorly to treatment for AR, although both may feature in exacerbating asthma. NAR can be: Infectious Vasomotor Occupational Hormonal Drug-induced Gustatory Non-allergic with eosinophilia syndrome (Ryan et al, 2008). There are several explanations for this. Pollen counts differ considerably from year to year. The expression or timing of pollination may vary in different parts of the country, typically with problems being less and later in the season the further north you go. In cities, the allergenicity may be enhanced or made worse by the presence of air pollutants, The mainstay in the management of NAR is, where possible, removal of the precipitant. For example, cessation of aspirin or beta blocker for drug-induced, or a reduction in alcohol intake or chilli consumption in gustatory rhinitis. A further confounding feature is the presence of allergic rhinitis (PAR). The for this are different, in that the nose is 54 JCN 2016, Vol 30, No 2

2 1 in 5 Figure 1. Pollen in the UK (adapted from the Met Office Pollen Count Calendar, blocked rather than runny, sneezing and eye are not as marked, with the predominant feature being nasal blockage. PAR, NAR and SAR may all co-exist. It is useful to stratify disease by severity and type. Allergic Rhinitis and its Impact on Asthma (ARIA) has a useful grid which facilitates this classification (Figure 2). Many patients who suffer from mild or do not seek formal medical help as they are able to purchase saline nasal irrigation, antihistamines, or topical nasal steroids over the counter without prescription. These generally meet their needs or render them symptom free, although there are no data to support this. It is mainly patients with moderate or disease who present for consultation (Bousquet et al, 2006; Figures 3 and 4). It is important to realise that AR is not a trivial disorder, as it impacts considerably on the people in the UK suffer from hay fever Tree pollen Weed pollen Grass pollen Pollen Calendar Main release period Peak Pollen type Jan Feb Mar Apr May Jun Jul Aug Sep Hazel (Corylus) Yew (Taxus) Alder (Alnus) Elm (Ulmus) Willow (Salix) Poplar (Populus) Birch (Betula) Ash (Fraxinus) Plane (Plandanus) Oak (Quercus) Pine (Pinus) Lime (Tilia) Grass (Poaceae) Dock (Rumex) Mugwort (Artemisia) Nettle (Urtica) Oilseed rape (Brassica Napus) Plantain (Plantago) life of the patient and his/her family (Valovirta et al, 2008). HISTORY-TAKING Important components in historytaking are: Nature and duration of Any personal or family history of allergic disorders Current medications being taken (including over the counter) An assessment of the impact the are having on the patient s quality of life. As with all patients, smoking history should be taken and specific enquiries made concerning asthma, which is present in up to 40% of those with AR (Guerra et al, 2002). Furthermore, up to 80% of those with asthma can also suffer with AR, which can be a confounding factor. Rhinitis, of whatever sort, predicts worse asthma control, higher incidence of exacerbations and hospitalisations, but the evidence that treating Average UK pollen levels Low 95% of hay fever sufferers are allergic to grass pollen Alcohol worsens hay fever Beer, wine and other spirits contain histamine the chemical that sets off allergy in the body rhinitis improves asthma is somewhat elusive. EXAMINATION Features of AR are nasal crease and Morgan Dennie lines. The lower part of the nose should be examined for signs of hypertrophy of the turbinates (indicating mucosal oedema), polyps, or deviation of the nasal septum. Investigations are not usually helpful or required in primary care. Skin prick tests may be performed, but this rarely happens in primary care. Specific immunoglobulin E (SIgE) tests may be undertaken, but, in the author s clinical opinion, they are expensive and serve little useful purpose at this time as the diagnosis should be based on the patient s history. MANAGEMENT High Very high It is helpful to have an understanding of the pathophysiology of AR, both to know what is happening and also to improve patient JCN 2016, Vol 30, No 2 55

3 Intermittent <4 days/weeks or <4 weeks at a time Persistent 4 days/weeks and 4 weeks at a time Cleans dried secretions Improves mucociliary clearance Reduces inflammatory markers. Saline nasal irrigation is available both over the counter and on prescription. Video instruction appears on both companies websites. Normal sleep Normal daily activities Normal work and school No troublesome Figure 2. Stratification of allergic rhinitis. education. The allergic reaction occurs when a pollen cross links with two SIgE molecules. These are resident on mast cells. This cross-linking triggers the release of pre-formed inflammatory mediators (Table 1). Of these, histamine is perhaps the most dominant and has an immediate effect (early allergic response), which is seen with sneezing, itching eyes and running of the eye and nose. Some patients also experience itchy tympanic membranes or palates. Those with asthma may have a sudden bout of coughing and wheezing. This initial reaction will last an hour or two, but the pre-formed mediators also recruit other cells, cytokines and chemokines to create a late phase response which is more characterised by nasal blockage, although the other may persist. Allergen avoidance This is, of course, the logical thing to do, but during the pollen season, pollens are ubiquitous, making it difficult to avoid them. Non-pharmacological strategies Pollen filters in cars are beneficial. Pollen levels are at their highest in the evening, so this is a good time to stay indoors. Drying clothes inside One or more items Abnormal sleep Impairment of daily activities, sport, leisure Problems caused at school or work Troublesome the house avoids transporting pollens inside. Wearing sunglasses may reduce the ocular impact of pollens. Some people find the application of nasal balms helpful. Saline nasal irrigation This aspect of care is often not considered in spite of a favourable Cochrane review (Harvey et al, 2007). It may be used alone or in conjunction with other therapies. The precise mode of action is unknown, but it: Washes away unwanted aeroallergens % patients (n=3,052) Over-the-counter remedies There is a range of medications available over the counter which may be beneficial. Although not recommended (Church et al, 2010), first-generation antihistamines are still on sale (Table 2). These have a greater incidence of drowsiness and may cause psychomotor retardation. Second-generation antihistamines (Table 3) are generally more effective and have a smaller range of side-effects, although drowsiness may still be a problem. As previously mentioned, histamine is the main mediator of the early allergic response. Antihistamines are best administered before exposure, i.e. two weeks before the start of the hay fever season. For protection to be maintained, antihistamines should be taken every day, without breaks on days when low pollen counts are forecast. In the author s clinical experience, this degree of compliance is essential for optimal results and needs to be communicated to patients. Figure 3. Profile of presenting in primary care, as found in Bousquet et al s study (2006) into the effect of allergic rhinitis on quality of life, sleep and work performance. 56 JCN 2016, Vol 30, No 2

4 Nasal congestion Itchy eyes Runny nose Itchy palate Adults Sneezing 9 7 Watering eyes 4 * Statistically significant difference 7 Itchy ears 4 Small base (n=69) Small base (n=68) 4 Itchy nose Percentage (%) Figure 4. Representation and quantification of the single most troublesome suffered by adults and children with AR, taken from an online survey of 2,355 individuals, from whom 2,002 (85%) had nasal congestion (adapted from Shedden, 2005). Decongestants Some patients find these medications helpful if their main are those of nasal congestion, i.e. blocked nose and sinus pain. Topical decongestants Topical decongestants, such as xylometazoline, oxymetalozine and ephedrine, have a rapid onset of action providing quick symptom relief. They need to be used frequently to maintain effect. They should not be used for more than 5 7 days, as tachyphylaxis and rhinitis medicamentosa (rebound congestion) occur, which is difficult to treat (Ramey et al, 2006). Oral decongestants, pseudoephedrine for example, is a vasoconstrictor agent which reduces mucosal swelling and opens up the sinuses and Eustachian tubes. Unlike topically administered vasoconstrictors, it does not cause rebound congestion, but its use may cause insomnia, anxiety, urinary retention and may exacerbate glaucoma (Bousquet et al, 2004). Topical nasal steroids Beclometasone and fluticasone are available over the counter. While they have some benefit in reducing the early allergic response, they are more useful in attenuating the latephase response. Globally, they are 9 Children * considered to be the most effective single agent (Brozek et al, 2010). They also have some beneficial effect on ocular. The newer topical steroids (fluticasone, mometasone) have the advantage of only being needed to be used once daily. Topical nasal antihistamines Currently, azelastine is the only nasal antihistamine available in the UK for topical nasal use, although it is also available as eye drops. Olopatadine is also available in eye-drop form. Topical nasal antihistamines have the advantage of having few, if any systemic side-effects, thus obviating the somnolence which can affect some 10% of second-generation antihistamine users, but also averting the risk of side-effects such as glaucoma or urinary retention. Cromoglycate/nedocromil These are available as eye drops. They work by stabilising mast cell membranes and reducing the liberation of inflammatory agents. They can be helpful in the management of ocular (González-López et al, 2012). Cromoglycate is also available as a nasal spray. Leucotriene receptor antagonists These tablets may be taken once daily and are particularly beneficial if the patient has lower respiratory tract asthma-type, i.e. cough, wheeze, chest tightness, or is aspirin sensitive. Oral corticosteroids Oral corticosteroids may be helpful as a short, sharp course for ly troubled patients. Although will be rapidly resolved, they will return just as quickly when the corticosteroids are stopped. However, they present an opportunity to start regular treatment at the same time to prevent recurring. Injectable corticosteroids There are still many people who are treated with injectable steroids Table 1: Pre-formed mediators Histamines Leucotrienes Prostaglandins Cytokines Interleukins Platelet-activating factor Table 2: First-generation antihistamines Alimemazine Chlorphenamine Clemastine Cyproheptadine Hydroxyzine Diphenhydramine Ketotifen Promethazine Brompheniramine Table 3: Second-generation antihistamines Cetirizine Loratidine Levocabastine (nasal spray) Azelastine (nasal spray) Fexofenadine Mizolastine Levocetirizine Rupatidine Desloratidine JCN 2016, Vol 30, No 2 57

5 every year. This form of therapy is not supported by guidelines because of the adverse risk benefit ratio. This technique is preferred by patients because, in general, it is effective with rapid onset of action and almost complete abolition of. The risks are those of avascular necrosis (AVN) of the femoral head (Weinstein, 2012), as well as all the other side-effects commonly associated with oral corticosteroids, such as weight gain, glucose intolerance, skin thinning and cataracts. Combination therapy Recently, a new preparation has been licensed for the management of AR. This is a combination of azelastine (an antihistamine) with fluticasone furoate (a corticosteroid) (Dymista, Meda Pharmaceuticals). It is administered twice daily by means of a topical nasal spray. Clinical trials have demonstrated that its use is associated with rapid onset of action and a greater effect than either of the constituent agents used as monotherapy (Carr et al, 2012; Bousquet et al, 2015). ARIA ( and the British Society of Allergy and Clinical Immunology have both produced guidelines for the management of AR ( ly/1hiutfa). Essentially, these guidelines adopt the same step-wise approach of adding on treatment to gain control (Figure 5). Both groups are currently revising their guidelines. 58 JCN 2016, Vol 30, No 2 Intra-nasal steroid Local cromone Oral or local non-sedative H1-blocker Intra-nasal decongestant (<10 days) or oral decongestant Allergen and irritant avoidance Figure 5. Treatment of allergic rhinitis (adapted from ARIA guidelines). PATIENT EDUCATION AND COUNSELLING Immunotherapy An integral part of patient management is patient education. Adherence throughout the hayfever season improves control of. Patients often decide not to take their medication if, for example, the forecast for the pollen count is low or it is raining. This means that they lose protection with a return of, which are more difficult to reduce once they become established. Thus, patients should be encouraged to adopt the routine of taking medication every day. Setting alarms on mobile phones is a good way of reminding patients to do this. It is also important to instruct patients on how to inhale nasal steroids, i.e. with a slow nasal inhalation, avoiding rapid sniffing. It is better if the spray stays in the nostril for a couple of minutes. Patients should first blow their nose to clean out any old mucous. Then gently inhale the nasal spray pointing the nozzle away from the nasal septum. This is best achieved by using the right hand for the left nostril and vice versa. There are a number of videos on You Tube, but none is perfect and they nearly all exhibit some side holding. The inhaler only needs to be primed before the first use, thereafter, it only needs to be primed if it has not been used for two weeks or more. One of the side-effects of nasal corticosteroids is nose bleeds. This is because: 1. If the nozzle is inserted into the nasal septum it may cause local trauma and bleeding 2. The mucous membrane overlying the septum is very thin. The action of nasal steroids further weakens the blood vessels, predisposing them to bleeding. This is not a problem on the lateral nasal wall, so teaching and explanation of nasal inhalation technique is important. Managing expectations Even in the best hands, most people do not achieve complete relief of. However, nearly everyone who takes their medications as prescribed will notice some improvement. For example, those with mild disease may have their eradicated completely, while those with may only achieve an improvement to moderate severity. Lifestyle factors Obviously, cigarette smoking makes matters far worse so advice on smoking cessation is important. Healthcare professionals should also give health promotion advice around exercise, keeping fit and alcohol consumption. One of the pharmacological effects of alcohol Revalidation Alert Having read this article, How you identify patients with allergic rhinitis How patient education and counselling can help people with allergic rhinitis Your knowledge of the main treatment options available for the condition. Then, upload the article to the new, free JCN revalidation e-portfolio as evidence of your continued learning:

6 is to cause nasal congestion and blockage. Immunotherapy This has fallen into abeyance since the Committee on Safety of Medicines decreed that immunotherapy should only be undertaken in places where there is immediate access to rescuscitation equipment in However, immunotherapy is still available in the UK, but is restricted to those with more therapy-resistant disease. Recently, immunotherapy administered sublingually has been introduced for grass and house dust mite (and ragweed in the United States). Patients who are suffering badly and who have positive SIgE blood tests should be referred to an allergist for consideration of immunotherapy. In the author s opinion, it is likely that immunotherapy will make a comeback in the not too distant future. There are now well-designed trials exhibiting the long-term benefits and cost effectiveness of this therapy (Durham et al, 2011). CONCLUSION AR is an increasingly common and disorder. A structured approach to history-taking and management is likely to improve outcomes for patients, who must also be educated about critical components of management, such as compliance and nasal inhalation technique. Major guidelines are currently in revision, namely the ARIA and BSACI guidelines. REFERENCES Bousquet J, van Cauwenberge P, Khaltaev N, et al (2004) ARIA in the pharmacy: management of allergic rhinitis in the pharmacy. Allergic rhinitis and its impact on asthma. Allergy 59(4): Bousquet J, Neukirch F, Bousquet PJ, et al (2006) Severity and impairment of allergic rhinitis in patients consulting in primary care. J Allergy Clin Immunol 117: Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A, et al (2008) Allergic rhinitis and its impact on asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen). Allergy 63 Suppl 86: Bousquet J, Bachert C, Canonica GW, Casale TB, Cruz AA, Lockey RJ, Zuberbier TJ (2009) Unmet needs in chronic upper airway disease (SCUAD). Allergy Clin Immunol 124(3): Bousquet J, Bachert C, Bernstein J, Canonica GW, Carr W, Dahl R, et al (2015) Advances in pharmacotherapy for the treatment of allergic rhinitis; MP29-02 (a novel formulation of azelastine hydrochloride and fluticasone propionate in an advanced delivery system) fills the gaps. Expert Opin Pharmacother 16(6): Brozek JL, Bousquet J, Baena-Cagnani CE, et al (2010) Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol 126(30: Carr W, Bernstein J, Lieberman P, Meltzer E, Bachert C, Price D, et al (2012) A novel intranasal therapy of azelastine with fluticasone for the treatment of allergic rhinitis. J Allergy Clin Immunol 129(5): Church MK, Maurer M, Simons (2010) Risk of first-generation H1- antihistamines: a GA2LEN position paper. Allergy 65(4): Committee on Safety of Medicines (1986) CSM update: Desensitising vaccines. Br Med J 293: 948 Durham SR, Emminger W, Kapp A, et al (2011) SQ-standardized sublingual grass immunotherapy: confirmation of disease modification 2 years after 3 years of treatment in a randomized trial. J Allergy Clin Immunol 129(3): González-López JJ, Morcillo-Laiz R, López-Alcalde J, et al (2012) Mast cell stabilisers for seasonal and perennial allergic conjunctivitis (Protocol). Cochrane Library, issue 12 Guerra S, Sherrill DL, Martinez FD, Barbee RA (2002) Rhinitis is an independent risk factor for adult-onset asthma. J Alergy Clin Immunol 109: Harvey R, Hannan S, Badia L, Scadding G (2007) Nasal saline irrigations for the of chronic rhinosinusitis. Cochrane database Syst Rev 18:CD Ramey JT, Bailen E, Lockey RF (2006) Rhinitis medicamentosa. J Investig Allergol Clin Immunol 16(3): Ryan D, van Weel C, Bousquet J, et al (2008) Primary care: the cornerstone of diagnosis of allergic rhinitis. Allergy 63(8): Shedden A (2005) Impact of nasal congestion on quality of life and work productivity in allergic rhinitis: findings from a large online survey. Treat Respir Med. 4: Valovirta E, Myrseth SE, Palkonen S (2008) The voice of the patients: allergic rhinitis is not a trivial disease. Curr Opin Allergy Clin Immunol 8(1): 1 9 Weinstein RS (2012) Glucocorticoidinduced osteoporosis and osteonecrosis. Endocrinal Metab Clin N Am 41(3): KEY POINTS Allergic rhinitis (AR) is a common disorder which has a major impact on the lives of sufferers and families. Although currently there is no cure for patients with this disease, a variety of therapeutic interventions can alleviate the. It is important that nurses are able to differentiate allergic and non-allergic rhinitis (NAR) from viral upper respiratory tract infections (URTIs) in order to best manage their patients. It is also necessary to ask appropriate questions of those patients attending for asthma review, as they may have unrecognised and untreated disease. Familiarity with the range of medications and their administration is advocated. Patients with troublesome, non-responding need to be referred, as do those with red flag signs. JCN 2016, Vol 30, No 2 59