Allergic Rhinitis refers to inflammation of the nasal passages which results in symptoms such as sneezing, nasal congestion and blockage. Rhinitis which is caused by an allergic trigger is known as Allergic Rhinitis (AR). This accounts for about 75% of rhinitis cases while the remaining 25% are caused by non-allergic rhinitis. It is estimated that over 80% of people with asthma have AR. It is also a risk factor for asthma with 10-40% of people who have AR also having asthma. AR is more likely to develop initially with asthma developing later. Therefore, people with AR should be assessed for asthma due to the increased risk of developing asthma. Similarly, patients with persistent asthma should be assessed for AR. As spring and summer emerges, this can be a challenging time as various pollen levels start to increase.
Table 1: Pharmacological options of allergic rhinitis
AR and asthma often co-exist as “united airway disease” or “one airway disease”. Both conditions are chronic inflammatory diseases affecting both the upper and lower airways. Both conditions can be triggered by allergic or non-allergic triggers and may present as several phenotypes. Assessment and management of AR and asthma should be jointly carried out, leading to better control of both conditions.
Rhinitis can occur without a known allergic trigger. This is known non-allergic rhinitis. Non AR accounts for about 25% of rhinitis cases. Non-allergic rhinitis can be caused by structural nasal problems such as septal deviation and through exposure to environmental
pollution, chlorinated pools and even fragrances. Hormonal changes that occur during puberty, pregnancy and menopause can also act as a trigger.
Symptoms of Allergic Rhinitis
Typical symptoms of seasonal (Hayfever) and perennial allergic rhinitis are
• Sneezing
• Itchy, blocked, or runny nose
• Red, itchy, or watery eyes
• Itchy throat, inner ear, or mouth
• Postnasal drip (a drip of mucus from the back of the nose into the throat)
• Headaches
• Loss of concentration and generally feeling unwell
• Reduced sensation of taste and smell
Patients may experience all or some of the above. Symptoms may be confused with symptoms of COVID19.
Classification
In 2019, the classification of “seasonal” and “perennial” rhinitis was changed to “intermittent” and “perennial” rhinitis (ARIA, 2019). Intermittent rhinitis occurs less than 4 days per week or for less than 4 weeks. Persistent rhinitis lasts more than 4 days and longer than 4 weeks. Both intermittent and persistent AR can be mild or moderate/severe (see Figure 1).
Pharmacological interventions ARIA 2019
There are several treatment options available to the patient and a combination of these options may be required for optimal relief of symptoms. These are outlined in Table 1. Saline douching/ nasal irrigation should also be encouraged and is available either as a saline rinse or saline spray. Saline rinsing involves high volume at a low pressure whereas saline spray is a low volume delivered at high pressure. The advantages of saline douching include:
• Direct cleansing
• Removal of mucous and inflammatory mediators
• Reduces bacterial burden
• Reduces mucus thickness
• Improves mucocillary function by increasing ciliary beat frequency
Smoking and vaping cessation should be encouraged at every opportunity. Smoking and vaping increases the likelihood of chronic nasal symptoms and may be associated with the development of nasal polyposis. Passive smoking, environmental exposure and passive vaping also increase the likelihood of chronic nasal symptoms and nasal polyposis. Mild intermittent AR treatment options include oral and nasal decongestants which can be used as a rescue medication. These medications will reduce nasal congestion and should be used for no longer than 7 days and should be avoided in pregnancy and breastfeeding. Oral H1 antagonists block the physiological effects from mast cell-derived histamine. 2nd generation antihistamines are preferred due to their less sedating effect and are available over the counter. Antihistamines are also available intranasally or intraocular. Intranasal corticosteroid (INCS) is the 1st line treatment for
Figure 1: Classification of allergic rhinitis (ARIA, 2019)
ARIA recommendation for management of allergic rhinitis
Figure 2: Stepwise pharmacological treatment for allergic rhinitis
moderate/severe intermittent and persistent AR. These medications are used once or twice daily to each nostril and good technique is essential and should be checked at every opportunity. If the nasal cavity is very obstructed, a nasal spray may not be effective. Nasal drops may be more effective in this scenario. Nasal spray and nasal drop technique can be viewed on https://www.asthma.ie/ about-asthma/resources/inhalertechnique-videos.
The efficacy of INCS is not improved when used with oral corticosteroids (OCS).
Sublingual Immunotherapy (SLIT)/ Allergen Immunotherapy (AIT) is now recommended by GINA (2021) as a treatment option for patients with asthma who are sensitised and have allergic rhinitis. Immunotherapy is also recommended by ARIA (2019) for patients with AR who do not achieve an optimal response from oral H1 or INCS therapies. These medications are not available on the GMS and can be prescribed by GPs.
Immunotherapy
Sublingual immunotherapy (SLIT)/ Allergen Immunotherapy (AIT) is recommended by GINA (2021) as a treatment option for patients who are sensitised and have allergic rhinitis. Immunotherapy is also recommended by ARIA (2019) for patients who have AR and who do not get an optimal response from oral H1 or INCS therapies. There are three SLIT/AIT products available in Ireland to treat allergy grass pollen, tree pollen and house dust mite allergy. These are taken sublingually daily for three years.
Endonasal Phototherapy
Endonasal phototherapy has an immunosuppressive effect by inhibiting allergen-induced histamine released from mast cells. It also induces apoptosis in the T-lymphocytes and eosinophils. The procedure directs a combination of UV-B. UV-A and visible light into the nasal cavity. Endonasal phototherapy is generally well tolerated and effective and is a treatment option when pharmacological treatment is insufficient or contraindicated.
Surgical Intervention
It is considered that allergic rhinitis is a medical condition that requires medical intervention. However, if symptoms are unilateral or if there is a septal deviation, nasal polyps or tumour present, surgery should be considered. Patients will still need to have an AR plan in place post-surgical intervention.
Lifestyle Intervention
• Keep windows closed at night-time or when the pollen count is high.
• Monitor the pollen levels on https://www.met.ie/forecasts/ pollen
• Minimize time spent outdoors when the pollen count is high.
• Apply Vaseline around nostrils when outdoors to trap pollen.
• Wear wraparound sunglasses to minimize levels of pollen irritating the eyes.
• Splash the eyes with cold water to help flush out pollen and soothe and cool the eyes.
• Shower, wash your hair and change clothes if you have been outdoors for an extended time.
• Exercise in the morning rather than the evening when there are higher rates of pollen falling.
• Avoid drying clothes outdoors and shake clothes outside before bringing them inside –particularly bedclothes.
• Minimise contact with pets that have been outdoors and are likely to carry pollen.
• Have an Asthma Action Plan in place which contains all the information a person with asthma needs to keep their condition in control. Every person with asthma should be offered a plan. It should be reviewed frequently, and any time medication is changed. These can be downloaded for free from www.asthma.ie and should be filled out with the patient’s healthcare professional.
Exam time…
Walker et al (2007) showed that allergic rhinitis can have a significant impact on exam performance and results with students dropping a grade in the state exams compared with their mock exams. Students should be advised to have their allergic rhinitis assessed and treatment started well in advance of sitting exams, usually around Easter time. Some other useful tips during exam time include:
• Use non-sedating anti-histamines
• Students should tell the adjudicator if their seasonal allergic rhinitis is bothering them.
• Splash the eyes with cold water before going into the exam room.
• Try not to sit near an open window.
• Keep a supply of tissues and effective, quick-acting treatments close at hand just in case.
Special Considerations in Allergic Rhinitis
Children under 4 years
Outdoor allergens are unusual in children under 2 years of age. Type 2 sub-endotype IL4/ IL-13 are associated with AR in children. IL-5 is associated with asthma. Treatment of children under 4 should focus on allergen avoidance and saline spray. Cetirizine is the oral H1 antagonist of choice. Cetirizine is licensed
From 2 years, but good safety is reported from 6 months of age. For moderate/severe persistent AR, intranasal corticosteroids such as Fluticasone or Mometasone should be considered 1st line treatment. Long-term follow-up studies suggest no growth retardation if used as a once-daily dose. Caution should be taken in children who are also using inhaled or topical corticosteroids for asthma or dermatitis. In children, with resistant symptoms and those with co-existing asthma, leukotriene receptor antagonists should be considered. Parents should be educated about possible side effects of sleep disturbance and mood disorders.
Pregnancy
AR affects 20% of pregnancies and women with pre-existing AR can experience an increase in symptoms. Medications should be avoided where possible and should be used if benefits to the mother are greater than the risk to the foetus. Medication should be avoided in the first trimester if possible. Topical administration of medication should be the first line where possible.
Conclusion
This article has explored the assessment and management of AR. Special considerations in children and pregnancy have also been addressed. The impact of allergic rhinitis on health and well-being is significant, with many people experiencing impairment of daily activities, learning and cognitive function, as well as reduced productivity at work and school. Optimal control of symptoms through pharmacological and non-pharmacological treatment regimes in combination with education, self-management and empowerment is paramount to managing this distressing condition.
Patient Resources
People who have questions about managing their asthma are encouraged to send a WhatsApp message to the HSE-funded Asthma WhatsApp service on 086 059 0132 or Freephone the Asthma Society’s HSE-funded Asthma Adviceline on 1800 44 54 64. Both services are free and allow users to communicate directly with an asthma nurse specialist. Pharmacists can refer patients to these services using the e-referral form at https://www. asthma.ie/patient-e-referral. The annual Asthma Society Hayfever Campaign will be running over the coming months with media engagement amongst its activities.
References available on request
