Drs Samantha Walker and Aziz Sheikh discuss current recommendations for the treatment of allergic rhinitis, highlighting important issues for general practice
Rhinitis is a commonly presenting symptom in general practice, and is associated with significant morbidity. There are a number of guidelines for the treatment of rhinitis, but most, if not all, are consensus based. Furthermore, they are frequently written by experts, with little involvement from generalists, so they may not always be wholly relevant to primary care.
However, there are a number of systematic reviews in progress designed to assess the effectiveness of different treatment options for the management of rhinitis. It is hoped that this will lead to the development of evidence-based guidelines.1,2
Where possible it is important to identify and treat the underlying disorder. Diagnosis has been covered by Loke and Woolford in this issue. In allergic rhinitis, identification of avoidable triggers may be important, and avoidance (where possible) should be combined with symptomatic treatment.
A very large number of randomised controlled trials have shown that non-sedating antihistamines and nasal corticosteroids confer benefit, with corticosteroid the superior treatment.3-5
Treatment choices should be based on efficacy, safety, and compliance, guided by patient preference.
Current recommendations are based on the most recent guidelines from the British Society for Allergy and Clinical Immunology (BSACI)6 and highlight key issues in the GP treatment of rhinitis. Figure 1 (below) shows a summarised and adapted form of these guidelines.
|Figure 1: Algorithm for the management of rhinitis (adapted from the BSACI guidelines)|
The overriding thrust of the recommendations is correct identification of the underlying cause of the symptoms and, where possible, symptomatic treatment.
Mild, intermittent symptoms
Identification and avoidance of the trigger allergen in those with allergic disease may be helpful. Suggestions include:
- Avoid pollen exposure where possible (taking a holiday abroad or by the sea during the peak pollen season and ensuring that the car has a pollen filter)
- Keep furry pets outside
- Minimise house dust mite exposure by encasing the mattress and bedding in mite-impermeable covers.
Low levels of mite allergen in the home have been shown to correlate with lower levels of non-specific bronchial hyperresponsiveness,7 although there is conflicting evidence for the efficacy of house dust mite avoidance measures in the home.8, 9
The multifactorial nature of perennial allergic rhinitis means that it is perhaps less likely to respond to simple avoidance measures.
Pharmacological treatment should include a non-sedating antihistamine (e.g. loratadine, cetirizine, desloratadine, fexofenadine) taken as required to control symptoms. If symptoms are confined to the eyes or nose, topical application of an antihistamine (e.g. azelastine, levocabastine) or sodium cromoglicate may be sufficient to control symptoms.
Persistent symptoms (moderate/ severe)
For persistent, moderate or severe symptoms, the choice of drug treatment should be based on the primary symptom, although optimal symptom control is likely to be achieved with a combination of treatments.
Nasal blockage: first-line treatment for nasal blockage is daily application of a topical nasal steroid (e.g. fluticasone, mometasone, budesonide, or beclometasone).4
Antihistamines are less effective in the treatment of nasal blockage, although newer antihistamines such as desloratadine may be helpful.
Prescription of topical nasal sprays should always be accompanied by an explanation of device technique. Devices should be used according to manufacturers instructions; sniffing hard during application may result in the drug being swallowed rather than remaining in the nose.
Patient information should include:
- The need for daily application
- Potential side-effects (crusting or bleeding; problems usually caused by poor device technique, which resolve with retraining, and sneezing, which tends to resolve as nasal hyperreactivity decreases)
- The need for persistence with treatment to experience maximal effects.
Serious side-effects to nasal steroids are rare at conventional doses, although care should be taken when corticosteroids are administered concurrently via alternative routes (e.g. via inhalers/skin creams).
Growth suppression in children has been reported with budesonide at 400µg daily and with beclometasone 168µg twice daily when used regularly for 1 year,10 but not with mometasone 100µg daily.
Patients should be followed up 2 weeks after symptom onset; if symptoms are uncontrolled, consider checking compliance, nasal technique and diagnosis; alternatively, increase the dose or try a different nasal steroid.
If symptoms remain uncontrolled on subsequent follow-up, check the original diagnosis, and consider referral to an allergist/ENT surgeon.
Rhinorrhoea, itching, sneezing: These usually respond best to a combination of a daily topical nasal steroid and a non-sedating antihistamine.
If symptoms are unresponsive, try an alternative antihistamine, check compliance and nasal spray technique. Alternatively, consider increasing the dose of nasal steroid, or try another nasal steroid. Another alternative is to add ipratropium bromide, which may help to control watery rhinorrhoea.
If symptoms remain uncontrolled, oral prednisolone (20mg/day) for 5 days may relieve acute symptoms, although the evidence to support this intervention is limited.
Depot triamcinolone is no longer recommended in the UK because of concerns regarding adverse events associated with its use.11
Grass pollen immunotherapy may be effective at reducing symptoms and medication scores in patients with seasonal allergic rhinitis symptoms that are unresponsive to treatment12 and is available from specialist centres.
- See also editorial on 'Why accurate history taking is essential in allergic rhinitis' in this issue.
- Alves B, Sheikh A, Hurwitz B, Durham SR. Allergen injection immunotherapy for seasonal allergic rhinitis (Protocol for a Cochrane Review). In: The Cochrane Library, Issue 1, 2001. Oxford: Update Software.
- Sheikh A, Nolan D, Hurwitz B. House dust mite avoidance measures for perennial allergic rhinitis (Protocol for a Cochrane Review). In: The Cochrane Library, Issue 1, 2001. Oxford: Update Software.
- Bousquet J, Van Cauwenberge P, Bachert C. Allergic Rhinitis and its impact on asthma (ARIA). WHO Position Paper, 2000.
- Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus oral H1-receptor antagonists in allergic rhinitis: systemic review of randomised controlled trials. Br Med J 1998; 317: 1624-9.
- Van Caewenberge P, Juniper EF and the STAR Investigating Group. Comparison of the efficacy, safety and quality of life provided by fexofenadine hydrochloride 120mg, loratadine 10mg and placebo administered once daily for the treatment of seasonal allergic rhinitis. Clin Exp Allergy 2000; 30: 891-9.
- Scadding GK, Drake-Lee A, Durham SR et al. Rhinitis Management Guidelines. London: Martin Dunitz, 2000.
- Maestrelli P, Zanolla L, Puccinelli P, Pozzan M, Fabbri M. Low domestic exposure to house mite allergens (Der p 1) is associated with a reduced non-specific bronchial hyperresponsiveness in mite-sensitised asthmatic subjects under optimal drug treatment. Clin Exp Allergy 2001; 31(5): 715-21.
- Custovic A, Simpson A, Chapman MD, Woodcock A. Allergen avoidance in the treatment of asthma and atopic disorders. Thorax 1998; 53: 63-72.
- Gotzsche PC, Hammarquist C, Burr M. House dust mite control measures in the management of asthma: meta-analysis. Br Med J 1998; 317: 1105-10.
- Skoner DP, Rachelefsky GS, Meltzer EO et al. Detection of growth suppression in children during treatment with intranasal beclomethasone dipropionate. Pediatrics 2000; 105(2): e23.
- Drug and Therapeutics Bulletin 1999; 37: 17.
- Walker SM, Pajno G, Torres Lima M et al. Grass pollen immunotherapy for seasonal rhinitis and asthma: a randomised controlled trial. J Allergy Clin Immunol 2001; 107: 87-93.