3 years after COVID started in Ireland, the last thing that we need is another medical problem, this one however, can be managed very well in most cases. Thankfully, this time we are talking about seasonal Allergic Rhinoconjunctivitis or Hayfever.
Written by Dr Ranbir Kaulsay MD, FACAAI, MSc Allergy (U.K) MB BCh BAO LRCP & SI (Irl), Dip Allergy (UK)
Fellow American College of Allergy, Asthma and Immunology, Consultant Medical Allergist, Bon Secours Consultants Clinic andBeacon Allergy Clinic
www.dublinallergy.com
However, it has been globally recognised that with worldwide climate changes, the pollen season has been getting longer and more severe throughout the whole world.
That certainly sounds like a Medical Apocalypse indeed. It is undisputed that Climate Change and Global warming are a reality.
The impact of such a change is wide and far – reaching and has even had an impact on our weather patterns, and as far as Ireland is concerned, we have experienced milder winters and very pleasant summers over the last few years with some counties experiencing an increase in natural phenomena such as flooding unfortunately and some unfortunate countries suffering from periods of extended drought. However generally it has resulted in much more pleasant weather in Ireland with longer and stronger pollen levels.
However, we have had some bizarre and unusual changes in our predicated weather patterns and these in turn have caused some changes in our flora and fauna.
However, all is not rosy, as we have seen a Marked increase in CO2, temperature which has led to a much longer and more intense pollen season. There has also been a marked increase in temperature recently which has caused high levels of tree pollen to surge, and this has caused what is known as a ‘pollen bomb’ effect to occur. Dangerous increase in pollen levels have been noted to cause a lot of health concerns especially in patients who are asthmatic. Unfortunately, up to 80% of patients with asthma also have coexisting hay fever and this may have detrimental effects on their health with sudden reductions in their lung function and an increase in bronchial hyper – Indeed this summer, every pharmacy in the country will be inundated by walk-in and prescription patients looking for symptomatic relief for their symptoms of allergic rhino conjunctivitis and asthma. Unsurprisingly many patients with allergic skin conditions find that their eczema and other skin related conditions also flare up during this time.
Ireland, Our CO2 and Pollen Problem
Increased carbon dioxide levels which are found to be high in urban rather than rural areas also cause pollen to increase in areas where there shouldn’t be too high tree or grass pollen levels such as in cities. As we are all aware CO2 levels continue to rise especially in our cities which is why which is why there has been a global effort to try to reduce climate change.
Nonetheless, an increase in CO2 in general would be bad news for both the climate and will lead to an increase in our already increasing trend of Hay Fever.
Tips from Asthma Society of Ireland on how to survive hayfever season:
• Talk to doctor or pharmacist NOW about taking medication to prevent / reduce symptoms. Don’t wait until you feel unwell.
• Keep an eye daily on our pollen tracker on asthma.ie
• Keep windows closed in your bedroom at night
• Keep windows and doors closed when the pollen count is high
• Stay indoors as much as possible on high pollen days
• Stay away from grassy areas, especially when grass is freshly cut
• Put Vaseline around your nostrils to trap pollen. Newer products containing a barrier and anti-inflammatory preparations like ECTOIN such as nasal sprays, eye drops and even some creams have been quite effective in reducing pollen induced allergy.
• Wear wraparound sunglasses to stop pollen getting into your eyes
• Shower, wash your hair and change your clothes if you have been outside for an extended period
• Avoid drying clothes outdoors, or shake them outdoors before bringing them in
• Minimise your contact with pets who have been outdoors and are likely to be carrying pollen
• Consider a purifier with a built-in air quality sensor to remove allergens and pollutants from the air. There are numerous brands available and not all have been rigorously tested.
There are many unproven items such as hay fever bands available and some patients swear as to their effectiveness , although there is no scientific basis to their effectiveness.
These are the usual tips that one would receive about practical suggestions, but very few of these work with a significant effect especially during times of high pollen surges or high pollen seasons. It is imperative to plan ahead of time for patients who know that they suffer from hay fever so that optimum control can be attained early and well – especially for children and young adults sitting important exams during the summer months like the Junior – Cert and Leaving Cert, not to mention all other summer University final examinations. An international study has shown that school children who suffer from hay fever are more likely to experience a noticeable drop in exam performance. (ISAC study 1995/2007)
Unfortunately, it has been shown that most patients are unsatisfied with their curren control of allergic rhinitis and many patients find themselves on multiple medications to control the disease process. It was found that the most common medications used was a combination of antihistamines and
intranasal corticosteroids, still with less than adequate control.
Current guidelines for the treatment of allergic rhinitis based on the current ARIA (Allergic Rhinitis and its Impact on Asthma) place intranasal corticosteroids as the first line of therapy for the treatment of the disease. Second generation antihistamines may be required as may ocular mast-cell stabilisers (Cromogylates etc.). New combination intranasal antihistamine / corticosteroid sprays have proven effective in moderate to severe allergic rhinitis nd several studies including arecent local study has found this an effective treatment.
Diagnosis of Allergy
The definitive evidence of allergy, after appropriate history and examination should be done by either Specific IgE measurements or by skin prick testing. There is little value of Total IgE measurements and no role for non-medical tests such as Kinesiology, VEGA testing or food intolerance testing for rhinitis.
Medical Care
The management of allergic rhinitis consists of 4 major categories of treatment, (1) environmental control measures and allergen avoidance, (2) pharmacological management, and (3) immunotherapy (4) surgery.
Environmental control measures and allergen avoidance involve both the avoidance of known allergens (substances to which the patient has IgE-mediated hypersensitivity) and avoidance of nonspecific, or irritant, triggers. Consider environmental control measures, when practical, in all cases of allergic rhinitis. This reinforces the need for proper and accurate allergy testing.
Pollens and outdoor moulds
Because of their widespread presence in the outdoor air, pollens can be difficult to avoid. Reduction of outdoor exposure during the season in which a pollen is present can be somewhat helpful. However, it is not ideal to restrict the movement of patients when the weather becomes better, nor is it possible in most cases.
In general, tree pollens are present in the spring, grass pollens from the late spring through summer (April to August), and weed pollens from late summer through autumn, but exceptions to these seasonal patterns exist. Specific area specific pollens such as ragweed and rape seed may also be of importance in certain parts of Ireland. Certain Pollen counts tend to be higher on dry, sunny, windy days. Outdoor exposure can be limited during this time, but this may not be reliable because pollen counts can also be influenced by a number of other factors. Keeping the windows and doors of the house and car closed as much as possible during the pollen season (with air conditioning, if necessary, on recirculating mode) can be helpful. Taking a shower after outdoor exposure can be helpful by removing pollen that is stuck to the hair and skin.
Despite these measures, patients who are allergic to pollens usually continue to be symptomatic during the pollen season and usually require some other form of management. As with pollens, avoidance of outdoor/seasonal moulds may be difficult. Symptomatic therapy with newer generation antihistamines uo to three times the recommended doses at most, nasal corticosteroids and ideally immunotherapy for more severe cases may be necessary.
Treatment:
Antihistamines are the first line of treatment for most allergy symptoms and these medications have been in existence for over 60 years but have evolved slowly.
Older antihistamines such as Piriton have significant side effects such as drowsiness and also have strong anti-cholinergic effects. Eg – Dry mouth etc and unfortunately these are still being used as first line antihistamines today.
Loratidine, Ceterizine and Fexofenadine are newer antihistamines and these have evolved into Levoceterizine and Desloratidine which are more effective and have fewer side effects. These preparations are available over the counter in some pharmacies with Fexofenedine still needing a prescription.
One of the best and my personal new favourites is Bilastine or Drynol as it is called here because of its effectiveness, safety and non-drowsy property. As this is one of the newest antihistamines, it is still available only on prescription but is highly effective.
Nasal sprays
These nasal sprays remain the main treatments for Rhinitis and is divided into
1) Decongestant sprays – Very effective over the counter medications but should never be used for more than five days continuously.
2) Intranasal Corticosteroids – Very effective in Treating all the symptoms of rhinitis and can be used safely for prolonged treatment regimes.
3) Nasal saline washes and moisturisers – effective in washing out mucus and allergens and should be recommended.
4) Newer combination antihistamines and steroid therapy- extremely effective preparation available on prescription (Dymista & Ryaltris)) and has been proven to be effective for all types of rhinitis.
Sublingual (meaning ‘under the tongue) Immunotherapy
Sublingual immunotherapy (SLIT) is currently increasing in use, particularly in Europe because of its safety and efficacy and the fact that it is licenced and reimbursable for some patients.
We have had two sublingual immunotherapy treatments for grass pollen registered and available to us (by GMS and on the Drugs Payment Scheme) since 2008.
Oralair (6-grass pollen extract) and Grazax (Timothy Grass extract) has been used by me for patients with severe grass pollen allergy since 2008 where standard antihistamine and other medicines fail to provide relief). We have many patients on or having completed three years of treatment.
It is then effective in reducing hay fever for at least 5 -10 years after completion of treatment and as such may be considered to have a disease modifying effect (which means that some patients on it do not progress to asthma and other allergy illnesses).
Nonetheless, control of seasonal rhinitis and allergies in general has improved significantly, with many safe and effective treatments and options now available to our patients, young or old.
References
The Lancet Planetary Health
Volume 3, Issue 3, March 2019, Pages e124-e131
