What you need to know about allergic rhinitis
GP allergy expert Dr Dermot Ryan answers Dr Mandy Fry’s questions on nasal spray technique, antihistamine choice and whether oral or injected steroids have any place in hay fever
GP allergy expert Dr Dermot Ryan answers Dr Mandy Fry's questions on nasal spray technique, antihistamine choice and whether oral or injected steroids have any place in hay fever
1. What's the best way to use a steroid nasal spray and should we be checking patient's technique as we do asthma inhalers? What is the role of other forms of nasal preparations apart from nasal steroids, such as antihistamines or cromoglycate?
• With the head held upright; insert the nozzle into the nostril
• Squirt the first puff directly back (aiming at the occiput)
• Angle the second spray at about 45° and squirt into the upper nose.
I suggest patients do it at night just before they fall asleep and – if on twice a day – again in the morning before they get out of bed.
The most important piece of advice is not to sniff or snort. I tell my patients that this is not cocaine and they should not mimic a well-known model – that seems to register well and make a point. Sniffing transports all the topical medicine into the nasopharynx where it is swallowed and disappears into the stomach.
There is benefit in reviewing nasal inhalation technique. The main reason topical nasal steroids do not work is because of poor technique.
There does appear to be a role for other agents but they are not as efficacious as topical steroids. Cromoglycate needs to be administered four times per day, which does not help compliance, but nedocromil only needs to be administered twice daily.
Topical nasal decongestants are helpful. Like salbutamol or terbutaline for asthma, they give fairly rapid relief of symptoms. Unfortunately tachyphylaxis occurs rapidly, meaning means more frequent dosing to achieve the same effect and ending up with rebound nasal hyperreactivity or rhinitis medicamentosa, which is virtually untreatable.
Patients using topical nasal decongestants should be warned not to use them for longer than one week.
2. Every year our PCT recommends which antihistamines to use – primarily based on cost considerations. Is the assumption that they are all equally efficacious a legitimate one? Or are there particular circumstances in which you might choose one product over another?
There is little doubt that first-generation antihistamines such as chlorphenamine are effective in relieving symptoms, but that's as far as it goes. They are cheap and nasty medications and I believe their OTC status should be revoked. The side-effect profile is significant with impaired psychomotor activity.
Research on exam performance of children with allergic rhinitis showed those on first-generation antihistamines had significantly greater impairment, whereas those on second-generation antihistamines had improved performance.
Second-generation antihistamines – cetirizine, loratadine, fexofenadine – are superior in terms of side-effects, although some patients may still suffer drowsiness, in which case it is worth trying a different agent.
They are slightly more expensive but can also be purchased OTC very cheaply when asked for generically.
Third-generation antihistamines, which are really modified second-generation agents, are probably slightly purer and slightly more effective but are significantly more expensive.
It is difficult to justify their routine use, but they may well be helpful in those who suffer either side-effects or lack of efficacy of other medications.
3. Patients seem to be affected at different times of year because of their sensitivities to different allergens. Which pollens are particularly prevalent at which time of year? Are there any common cross-reactions either between different pollens or with certain foods?
Hazel yew and alder are the first pollens to appear in February with mugwort and heather the last – in July. Some unfortunate people have more than one intermittent allergic rhinitis (IAR) a year.
We have all noticed that because of the relatively cool and wet summers of the past two years, there was a remarkable fall in the incidence and severity of grass pollen IAR – now the preferred term – or classical UK hay fever.
There is some cross-reactivity between pollens and certain fruits – some of the common ones are:
• birch pollen can cross-react with apples, pears, almonds, peaches, apricots, cherries, plums, nectarines, prunes, kiwi, carrots, celery, fennel, parsley, coriander, parsnips, peppers and potatoes
• alder pollen may cross-react with celery, pears, apples, almonds, cherries, hazel nuts, peaches and parsley
• grass pollens may cross-react with melons, tomatoes and oranges
• mugwort pollen may cross-react with celery, fennel, carrots, parsley, coriander, sunflower and peppers.
4. I still have patients who ask for intramuscular triamcinolone (Kenalog) for their allergic symptoms. Are there any circumstances in which this would be a justifiable treatment option? What about short-term oral steroids to cover important events such as exams or weddings for patients who are severely affected – would this be preferable? What dose and duration would you suggest?
There have been no studies carried out on the use of Kenalog or injectable steroids since 1988. Clinical trial methodology has improved very much since that time, but in truth there is no recent evidence in high-quality clinical trials for or against1.
Having said that, depot steroids when used for whatever indication have an association with avascular necrosis of the head of femur2 – a heavy price to pay for being unwilling to take appropriate daily medication, and indefensible, as their use is not recommended by guidelines.
On the other hand, although there does not appear to be a huge evidence base, the short-term use of a five- to seven-day course of oral steroids to cover important events or at the beginning of therapy may well prove to be a very useful intervention with a limited risk of side-effects.
5. What is the current thinking about the use of immunotherapy such as grass pollen extracts? Which patients would these be suitable for?
Among allergists there is great enthusiasm for this, and a growing evidence base of its effectiveness, with much of the original research being done in the UK3.
Immunotherapy died a death in the UK following the Chief Medical Officer's letter in 1988 after a spate of deaths following the use of subcutaneous immunotherapy in primary care.
At that time there was poor standardisation of allergy extracts used, coupled with poor characterisation of patients. This meant its use was somewhat haphazard.
Immunotherapy has come a long way since then. Clinical trials have been conducted rigorously and there is no doubt that, in properly selected patients, it reduces symptoms and medication use, prevents new sensitisations and has even been shown to inhibit progression to asthma.
Sublingual immunotherapy (SLIT) has now arrived in the UK. Currently Grazax is licensed and indicated for use in the management of grass pollen hay fever, and has been shown to be effective, although it has not been evaluated by NICE and funding decisions are being made locally by PCTs.
Side-effects are common – mouth swelling, itching – but tend to be transient and to improve over time. It is likely that over the next few years we will see a rebirth of immunotherapy in the UK, probably managed in primary care.
6. Is allergic rhinitis in adults a lifelong condition or is it possible to grow out of it? I've had a number of patients whose symptoms have resolved upon moving out of the area, which I always attributed to allergen changes in their new environment – but sometimes they come back and their symptoms don't.
Allergic disorders are strange things. They do not obey ‘rules' like diabetes or hypertension, which makes their treatment interesting and changing. There is absolutely no doubt that even from year to year patients have different hay fever experiences.
This is due to a variety of factors including patient age, comorbidities, emotional state and stress levels, the weather, temperature, humidity and active or passive smoking.
There is a phenomenon known as the allergic march, which describes in broad terms how the manifestation of allergy changes as ageing occurs. It is a description but cannot make predictions for the individual patient.
In short, for each patient there will be an answer – and probably a different answer for each patient.
7. Some patients swear by homeopathy for allergic rhinitis – is there any evidence base for this suggestion? Do you need to vary the treatment each year or once they have a suitable preparation can they simply use the same one each year?
There is no good evidence in the medical literature to support the use of homeopathy.
I have always found the notion of homeopathy rather amusing, but recognise the importance and power of the placebo effect in any disease area. So my answer to the second question is, your guess is as good as mine.
8. How effective are environmental measures such as keeping the windows closed, humidifiers and using grass pollen filters on car air-conditioning systems? Are there any other particular strategies you would recommend?
They certainly have some effect. Filters in particular appear to have a benefit, as do fans that direct airflow away from the face. Pollen counts are highest in the evening so avoiding going out at this time of day seems to be good advice.
Drying clothes indoors also seems to help. Drying them outside on a sunny day allows pollens to settle on the clothing, which are then transported into the house, perpetuating the effect.
Sunglasses seem to diminish the effect of pollens on the allergic conjunctivitis part of hay fever.
9. What is the evidence base, if any, for regular consumption of local honey to prevent allergic responses in the summer? How much do you need to consume and how often? Presumably it is too late to start this year? Are there any other complementary approaches that might work?
Interestingly I have heard of this and know it is espoused as a form of therapy. The underlying principle is that locally sourced honey provides specific desensitisation to local pollens, leading to a reduction in symptoms.
But on searching online under the headings of allergic rhinitis/hay fever and honey, most references obtained refer to allergic and even anaphylactic reactions occurring to locally sourced honey. In this instance the low pollen count or presence of pollen-derived antigens clearly causes sensitisation, leading to more severe allergic reactions.
Following on from this, the answers to the other questions must be not known.
I am unaware of any other complementary approaches that might work.
10. What treatment options are most suitable for pregnant women with allergic rhinitis?
Pharmaceutical companies will not perform prospective trials in pregnant women. Nonetheless they all maintain databases of women who have been exposed to medications, either by accident or design.
There appears to be no excess of risk when using first- or second-generation antihistamines, although most would still avoid using unless essential. The topical nasal steroids mometasone and fluticasone are undoubtedly safe given the tiny amount that is absorbed systemically.
Dr Dermot Ryan is a GP in Loughborough, Leicestershire, and allergy lead of the General Practice Airways Group. He is also a research fellow at the University of Aberdeen and a member of both British and international rhinitis guidance groups.
Competing interests: Dr Ryan has received honoraria for lecturing from Schering Plough, MSD, AstraZeneca and ALK-Abelló
Dr Fry considers the answers to her questions
I like the way Dr Ryan has described the correct use of intra-nasal sprays and can think of some patients in whom it would be useful.
It's hard to convince some patients about the usefulness of IM steroids like Kenalog and the concept of using short term oral steroids at the initiation of therapy - as well as to cover important events - may persuade some to try alternatives.
There seems little to choose between the second generation antihistamines so I'm happy to continue to try and abide by the local prescribing policy each year.
I'd never really thought about drying clothes outside as possibly perpetuating symptoms so I'll bear that in mind.
I think I'll also continue to encourage suitably motivated patients to try local honey, although the prospect of anaphylaxis, whilst logical, was not one that I had previously considered.
I'll also try and keep abreast of developments regarding immunotherapy, particularly if – as Dr Ryan suggests - it becomes part of a primary care remit in the future.
Dr Mandy Fry is a GP in Cirencester, Gloucestershire, and senior primary care lecturer at Oxford Brookes University