Allergic Rhinitis Clinical Update

Contents

1. Overview of allergic rhinitis 
2. Clinical assessment including allergy testing 
3. Aeroallergen minimisation 
4. Pharmacotherapy and other treatment options

pdfASCIA HP Clinical Update Allergic Rhinitis 2017 v2643.70 KB

Introduction 

This document complements ASCIA allergic rhinitis e-training for health professionals which is available on the ASCIA website www.allergy.org.au/hp/hp-e-training 

These courses are intended to provide health professionals with information on allergic rhinitis, including:

Summary of Key Points

1. Overview of Allergic Rhinitis

Allergic rhinitis (also known as hay fever), is the most common allergic disorder in Australia and New Zealand. It is often underdiagnosed, undertreated and sub-optimally self-treated. Allergic rhinitis can have significant impact on sleep, concentration, learning and daily function, and affect childhood behaviour and development.

Patients often consider allergic rhinitis to be a nuisance, with no effective treatment. However, it can be effectively managed. The treatment of allergic rhinitis is important for the effective management of asthma.

Brief history

The term “hay fever” was used to describe seasonal allergic rhinitis from the late 18th century, when the prevailing belief was that the effluvium from new hay was the main cause of symptoms. In the late 19th century Dr Charles Blackley discovered that pollen was the major cause of seasonal allergic rhinitis. 

The cause of allergic rhinitis symptoms are wind pollinated trees, grasses and weeds. In 1906 the term “allergy” was first used, derived from the “allos” meaning “other” or a deviation from the original state and this was combined with “rhinitis”.  Therefore allergic rhinitis simply means “inflammation of the nose”. 

Allergic rhinitis is a local IgE mediated allergic condition, a response of the nasal airways to inhaled allergens.

allergic cascade 

Allergic rhinitis is common in Australia and New Zealand

Based on self-reports in the 2007-08 National Health Survey approximately 3.1 million Australians (15% of population) have allergic rhinitis. It was found to be most common between 15-54 years of age (peak between 25-44 years of age).

Common aeroallergen triggers of allergic rhinitis are:

Symptoms

The symptoms and signs of allergic rhinitis include:

Symptoms may be confused with recurrent upper respiratory tract infection. 

Clinical presentation of allergic rhinitis can be defined by timing of allergen exposure as follows:

Allergic rhinitis may be defined as occupational, being triggered by chemicals, irritants or allergens (e.g. animal dander) in the workplace. Symptoms simply improve when away from work.

Allergic rhinitis may also be classified by the duration and severity of symptoms as shown in the table below. 

duration and severity of symptoms 

Asthma and allergic rhinitis – the united airway disease

Allergic rhinitis and asthma are upper and lower respiratory tract manifestations of the same inflammatory process. This is known as the “united airway disease” (e.g. inhalation of aeroallergen via the nose may contribute to inflammation in the lungs). Allergic rhinitis is a risk factor for subsequent asthma development and effective treatment of allergic rhinitis improves asthma management. 

Patients with either asthma or allergic rhinitis should be assessed for coexistent disease because:

Thunderstorm asthma

Thunderstorm asthma epidemics and their tragic consequences highlight the need for more research, education and awareness in this area. Thunderstorm asthma is usually due to thunderstorms with rapid changes in wind, temperature and humidity. These cause pollen grains to absorb moisture, burst open and release large amounts of small pollen allergen particles, which penetrate into the small airways of the lung. Not all thunderstorms, even on days with high pollen counts, trigger thunderstorm asthma.

Not everyone affected by thunderstorm asthma epidemics has had thunderstorm asthma before. However, they have usually had severe allergic rhinitis and are allergic to ryegrass pollen.  Other allergens such as fungal spores, can also affect some people with asthma and other respiratory diseases during a thunderstorm. 

Further information on thunderstorm asthma is available at:

www.allergy.org.au/patients/asthma-and-allergy/thunderstorm-asthma 

ASCIA Treatment Plan for Allergic Rhinitis includes information on thunderstorm asthma:

www.allergy.org.au/patients/allergic-rhinitis-hay-fever-and-sinusitis/allergic-rhinitis-treatment-plan  

AusPollen Apps aim to provide accurate and easily accessible information on local pollen counts: www.pollenforecast.com.au

Allergic rhinitis can coexist with other conditions

As well as asthma, allergic rhinitis can coexist with a range of other conditions, including:

Nasal polyps and allergic rhinitis

Nasal polyposis (as with adult onset asthma) is not a simple allergic disease but may coexist with allergic rhinitis. Aspirin hypersensitivity is common in those with polyposis and asthma (Samter’s triad).

Polyps should be considered if patient presents with persistent nasal obstruction and/or anosmia. Large polyps may be seen on anterior rhinoscopy. Referral should be considered to an ear, nose and throat (ENT) surgeon or clinical immunology/allergy specialist with expertise in this area

Normal nose, inferior turbinate hypertrophy and polyp as examined on anterior rhinoscopy:

anterior rhinoscopy

Ears and allergic rhinitis

Allergic rhinitis may contribute to ear symptoms such as fullness, blockage, and/or hearing loss due to mucous and oedema in the Eustachian tube. Blockage of the Eustachian tube results in negative middle ear pressure and middle ear effusion (glue ear). Young children are more prone as they have eustachian tubes with a smaller diameter and an increased predisposition to recurrent upper respiratory infections.

Oral allergy syndrome and allergic rhinitis

Some people with pollen allergy will experience oral symptoms of itch and swelling in response to certain fresh vegetables and fruits. This is known as oral allergy syndrome (OAS). Serious OAS reactions are rare. OAS is thought to be due to cross-reactions between proteins found both in pollens and fruit/vegetables. In Australia, sensitisation to plantain weed is relatively common.  Some people with plantain allergy may also present with an oral allergy to certain fruits such as melons, tomato, orange and/or kiwi fruit. 

The role of the primary care physician is important in the management of allergic rhinitis 

The role includes:

2. Clinical Assessment 

Important questions in clinical history to consider

 

Timing of symptoms

Perennial (year round) and/or seasonal

Impact of symptoms

Mild (no effect on day-to-day function) or moderate-severe (impaired day-to-day function)

Frequency of symptoms

Intermittent (< 4 days/week or < 4 weeks) or persistent (≥ 4 days/week and for ≥ 4 weeks)

Triggers identifiable

Detailed home and/or work environment assessment (e.g. pets, occupation)

Coexistent conditions

Asthma, eczema (e.g. presence of other atopic conditions makes allergic rhinitis more likely)

Medications currently using/ previously tried and perceived efficacy – check appropriate use

Antihistamines
Intranasal corticosteroid sprays
Decongestants
Saline treatments
Other

Important signs on physical examination 

Face - signs of allergic rhinitis include:

 face

Nose - Each nostril should be examined with an otoscope.

nose examSigns of allergic rhinitis include:

 

ConjunctivaEyes - Signs of allergic conjunctivitis include:

Allergy Testing 

Pharmacotherapy for allergic rhinitis can be initiated without waiting for diagnostic allergy testing. However, testing increases the accuracy of diagnosis and identification of potential aeroallergen triggers. Diagnostic allergy testing involves either:

  1. Skin prick testing (SPT)

       or

  1. Serum specific IgE (ssIgE) levels (formerly known as RAST tests) to aeroallergens to determine the presence of sensitisation (IgE antibodies) and possible clinical relevance against suspected aeroallergen/s.

Both SPT and ssIgE testing detect the presence of IgE antibodies to potential allergens. These tests are considered to be surrogates for nasal allergy because they do not directly assess the response of the nasal mucosa to allergens. 

Limitations of allergy testing for aeroallergen sensitisation

SPT and ssIgE results must be interpreted by clinicians experienced in performing and interpreting these tests, taking into account the patient's clinical history.  This is important because:

Tests that are not useful include: 

Note: Acute onset rhinitis with symptom resolution typically occurs within 24 hours as part of an IgE mediated food allergic reaction, but this is not a cause of intermittent or persistent allergic rhinitis. 

Unproven and inappropriate methods that claim to test for allergy

Unproven methods include IgG testing, cytotoxic food testing, kinesiology, Vega testing, electrodermal testing, pulse testing, reflexology and hair analysis. They are not scientifically validated and may lead to unnecessary and costly avoidance strategies. There is no Medicare rebate for such tests in Australia or Pharmac rebate in New Zealand. These methods are not recommended by ASCIA or the World Allergy Organisation (WAO).

Further information is available from the ASCIA website: 

www.allergy.org.au/hp/papers/unorthodox-testing-and-treatment

Differential diagnosis

Non-allergic and allergic rhinitis can co-exist in the same patient.

Non-allergic rhinitis encompasses a range of disorders where rhinitis (nasal obstruction and/or rhinorrhea) is not caused by IgE mediated aeroallergen allergy. 

Differentials to consider

Key features

Chronic rhinosinusitis/polyposis

Anosmia, facial pressure/pain, muco-purulent discharge

Non-allergic rhinitis with eosinophilia

Negative allergy tests but > 20% eosinophils on nasal smear

Hormonal

Pregnancy

Menstrual cycle rhinitis

Drug induced

Typically aspirin and other NSAIDs. Range of other medications also reported (e.g. decongestants, ACE inhibitors, alpha-adrenoceptor antagonists, oral contraceptive pill, chlorpromazine, methyldopa and others)

Granulomatous diseases

External nasal swelling, sinusitis, nose bleeds, septal perforation, collapse of nasal bridge, multi-system involvement

Idiopathic/vasomotor rhinitis

Sudden onset and offset of watery nasal discharge

Can be triggered by strong smells or changes in environmental temperature

 Differential diagnosis to allergic rhinitis should be considered as shown in the table below. 

Feature

What to consider

Unilateral nasal obstruction

Foreign body in children, nasal polyp, deviated septum, tumor

Discharge

  • Bloody, muco-purulent discharge
  • Unilateral nasal discharge

Chronic rhinosinusitis or super-imposed infection
Foreign body (children), CSF leakage

Negative allergy tests

Correct aeroallergens selected
Non-allergic rhinitis

Failure respond to allergic rhinitis therapy

Compliance
Non-allergic rhinitis

When to consider referral to a specialist

Referral to a clinical immunology/allergy specialist should be considered if: 

Referral to an ENT specialist/surgeon should be considered if there is medically refractory nasal obstruction.

3. Aeroallergen minimisation 

Avoidance or minimisation of confirmed allergen/s may assist some individuals in reducing severity of allergic rhinitis symptoms. However:

House dust mites

House dust mite minimisation

Pollens

Pollens that cause allergic rhinitis are usually:

Pollen minimisation

Pet dander

Pet dander minimisation

Moulds 

Mould avoidance

4. Pharmacotherapy and other treatment options 

Duration and severity of allergic rhinitis symptoms are useful in guiding therapy, as shown in the table below.

AR Chart Pharmacotherapy and other treatment options

Allergic rhinitis pharmacotherapy options

Usual 1st line treatment options

Other possible treatments

Short term treatment options

Antihistamines (non-sedating oral or intranasal)

Saline treatments

Decongestants (oral or intranasal)

Intranasal corticosteroid sprays

Intranasal chromones

Systemic oral corticosteroids

Combination treatments (Intranasal corticosteroid and antihistamine sprays)

Intranasal anticholinergic sprays

Combination treatments (Intranasal decongestant and antihistamine sprays)

 

Oral leukotriene antagonists

 

Note:

Allergic rhinitis pharmacotherapy principles
Non-sedating antihistamines 

Place in therapy

1st line for intermittent mild allergic rhinitis or used in conjunction with other therapies

Route

  • Oral
  • Intranasal

Rapid onset action (1-2 hours)

Very rapid onset action (within 30 minutes). May be used as a rescue medication to provide immediate relief of symptoms

Over the counter

+

Type

Non-sedating; sedating antihistamines are not recommended

Frequency of use

Once or twice a day

Benefits

  • Ocular symptoms
  • Nasal sneeze/itch/runny nose
  • Nasal congestion

 

↓ itchy, watery eyes
↓ sneezing, itchy, runny nose
Limited*

Disadvantages

Cost

Note:  Whilst some nasal antihistamines can reduce nasal congestion, intranasal corticosteroids (INCS) are more effective in reducing nasal congestion. 

Intranasal corticosteroids (INCS) 

Place in therapy

1st line for persistent and/or moderate to severe allergic rhinitis and treatment failures with antihistamines alone

Over the counter

+ (or prescribed by a doctor)

Age restriction

Different intranasal corticosteroids often have different minimum age restrictions

Frequency of use

  • Continuous (more effective; few days to take effect; maximal effect by 2 weeks)
  • Long term use is recommended where effective
  • As-needed basis (less effective)

Benefits

  • Ocular symptoms
  • Nasal sneeze/itch/runny nose
  • Nasal congestion
  • Cost effective reduction of symptoms

 

↓ itchy, watery eyes
↓ sneezing, itching, runny nose
↓ nasal congestion

Disadvantages

Nasal irritation and bleeding may occur (uncommon)

Note:

Intranasal corticosteroids (INCS) side effects

Correct administration of INCS

Correct administration of INCS1. Prime the spray device according to manufacturer’s instructions (for first time or after a period of non-use).

2. Shake the bottle before each use.

3. Blow nose before spraying if blocked by mucous.

4. Tilt head slightly forward and gently insert nozzle into nostril.  Use right hand for left nostril (and left hand for right nostril).

5. Aim the nozzle away from middle of the nose and direct nozzle into the nasal passage (not upwards towards tip of nose but in line with the roof of the mouth).

6. Avoid sniffing hard during or after spraying.

Other treatment options

Saline nasal irrigation

Intranasal chromones (e.g. sodium cromoglycate)

Intranasal ipratropium

Oral leukotriene antagonists

Decongestants

Systemic steroids for allergic rhinitis

Surgery for rhinitis

Ocular management

Management of allergic rhinitis in pregnancy
Management of allergic rhinitis during lactation 

It  is recommended that medications are given after a feed to minimise any potential infant exposure.

During lactation

Medication

Considered safe

  • Saline nasal treatments
  • Intranasal sodium cromoglycate (chromone)
  • Intranasal ipatropium (anti-cholinergic)
  • Non-sedating oral antihistamines  (2nd generation)
  • Intranasal corticosteroids

Evidence for safety lacking (recommend not use)

  • Intranasal azelastine hydrochloride (antihistamine)
  • Intranasal lodoxamide trometamol (chromone)

Crosses into breast-milk (recommend not use)

  • Oral or intranasal decongestants
  • Intranasal levocabastine hydrochloride (antihistamine)

Dietary manipulation in allergic rhinitis

There is no evidence that allergic rhinitis is due to food allergies or food intolerances and therefore food elimination (e.g. cow’s milk, wheat) is not recommended, and has potential for serious nutritional consequences, especially in young children.  Restricting dairy products is often popular, but studies do not show any change in mucus production following dietary modification.

Some case series report rhinitis triggered in some individuals by preservatives. History is critical as no diagnostic tests are available to confirm this.

Lack of evidence for complementary medicines in allergic rhinitis

Alternative allergy tests are not regulated in Australia or New Zealand.  There is no Medicare or Pharmac rebate available and there is no evidence to support their accuracy in diagnosing allergic disorders.

Therapeutic efficacy of complementary-alternative treatments for allergic rhinitis (e.g. acupuncture, vitamin supplements, homeopathy, and physical therapies such as chiropractic-spinal manipulation) is not supported by currently available evidence. 

Allergen immunotherapy is an option for treating allergic rhinitis

Allergen immunotherapy (also known as desensitisation):

Benefits of allergen immunotherapy for allergic rhinitis

Commercial aeroallergens available for allergen immunotherapy in Australia and New Zealand:

Referring a patient for allergen immunotherapy

Consider referring a patient for allergen immunotherapy when:

For further information on allergen immunotherapy refer to ASCIA allergen immunotherapy e-training for health professionals www.allergy.org.au/hp/hp-e-training

Further information 

Australasian Society of Clinical Immunology and Allergy (ASCIA) www.allergy.org.au

The peak professional body of allergy and clinical immunology specialists in Australia and New Zealand.

The ASCIA website includes:

Patient support organisations

© ASCIA 2019

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Content updated November 2019