Drs Liz Angier (left), Shuaib Nasser, Imran Rafi, and Glenis Scadding highlight the need for a comprehensive clinical assessment to differentiate between rhinitis subtypes


Rhinitis, which affects around 20% of the UK population,1 is a common problem in primary care, but is often poorly diagnosed and under treated, even by GPs with a self-declared interest in allergic and respiratory disorders.2

Over 80% of patients with asthma may have co-existing rhinitis; rhinitis is also a risk factor for development of asthma.3 Asthma tends to be more severe in patients with perennial rhinitis, and bronchial hyper-reactivity can be reduced by using nasal corticosteroids. Patients with asthma whose rhinitis is well treated have fewer emergency visits and hospital admissions.4

This article:

  • provides an overview of the 2008 British Society for Allergy and Clinical Immunology (BSACI) guideline on the management of allergic and non-allergic rhinitis1
  • revisits the Guidelines in Practice article on this guidance published in 2008 5
  • discusses updates and barriers to implementation.

The article aims to raise awareness of rhinitis and encourage primary care practitioners to see this as an important and highly treatable and rewarding condition to manage. The strong link between diseases of the upper and lower airway is also emphasised. Rhinitis symptoms are often down played by patients and healthcare professionals but affect quality of life and performance and can also be part of multisystem allergic disease. It is therefore important to treat patients holistically and review them if they are unresponsive to treatment.

Rhinitis is characterised by nasal itching, sneezing, discharge, and blockage. It can be allergic, non-allergic, infective, or a combination of these. If untreated, rhinitis can have potentially detrimental outcomes:

  • An adverse effect on quality of life,6 which can affect both school performance7 and work life8
  • Development of co-morbidities, such as asthma, rhinosinusitis, otitis media, vocal and sleep problems, and conjunctivitis1
  • Chronicity, unresponsiveness to treatment, and irreversibility.

Allergic rhinitis

Up to one in five Europeans may be affected by allergic rhinitis9 and this prevalence is increasing: in a Swedish study the prevalence doubled over 12 years to 30% in 7-year-old children.10 The strongest risk factor is a family history of atopy with sensitisation to indoor allergens.3 Allergy accounts for the majority of paediatric rhinitis cases while in adults it causes approximately one-third of cases.1

Physiology

Allergic rhinitis is associated with a biphasic immunological response to an allergen: the early phase reaction occurs within minutes and results from IgE-mediated mast cell degranulation and release of chemical mediators such as histamine, leukotrienes, and prostaglandins, whereas the late-phase reaction that occurs several hours later and lasts for 12–24 hours is associated with activation of a distinct subset of T cells, so-called Th2 cells and the recruitment, activation, and prolonged survival of eosinophils in tissues.1

The common allergens responsible for perennial rhinitis include house dust, mites, and animal dander. A major cause of morbidity in the UK is seasonal exposure to the pollens of trees, grasses, weeds and mould spores. Occupational exposure to flour, latex, and wood dust (allergens often associated with the subsequent development of asthma) can cause chronic severe and long-lasting rhinitis. In addition, non-specific irritants such as smoke, cold air, air conditioning, and organic solvents can aggravate pre-existing rhinitis.1 Viral colds are more frequent and last longer in children with allergic rhinitis. Common causes of occupational rhinitis are shown in Table 1 (below).

Table 1: Common causes of occupational rhinitis1
Agents High molecular weight Low molecular weight Industry
Animal proteins Mouse, rat, guinea pig, crabs, etc. urinary and epithelial proteins Laboratory research, animal breeding, crab processing industry
Vegetable proteins Wheat and other cereal flours and grains, latex Baking, milling, food processing, hospital workers
Enzymes Protease, amylase, cellulase, lipase Food processing, detergent manufacture, pharmaceuticals
Pharmaceuticals Antibiotics, morphine, cimetidine Pharmaceutical manufacture and dispensing
Chemicals Diisocyanates, colophony fumes, (trimellitic) acid anhydrides (TMA), cyanoacrylates, epoxy resins, alkyd/polyunsaturated polyester resins Spray painting, electronic soldering, plastics and paint manufacture, vinyl flooring, resin production
Reproduced with kind permission from BSACI. Scadding G, Durham, S, Mirakian R et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy 2008; 38 (1): 19–42.

Presentation

Allergic rhinitis is associated with intermittent or persistent symptoms:1

  • Intermittent symptoms—affect an individual for less than 4 weeks and/or less than 4 days a week
  • Persistent—occur on 4 days or more a week and/or last for more than 4 weeks.

Symptoms are also classified as mild or moderate to severe:1

  • Mild—do not affect sleep, daily activities, school, or work
  • Moderate to severe—the patient exhibits one or more of the following: sleep disturbance, interference with daily activities, disruption of school or work, troublesome symptoms.

When to suspect allergic rhinitis

A diagnosis of allergic rhinitis should be considered if there is:1

  • a family history of atopy, asthma, or seasonal rhinitis
  • a personal history of asthma
  • seasonal variation in symptoms
  • a work-related or animal-related trigger.

Symptoms and signs of allergic rhinitis

The most obvious symptoms and signs of allergic rhinitis are:1

  • associated eye symptoms
  • itching of the palate and nose and sneezing
  • watery anterior nasal discharge

Examination of the nose may reveal a transverse nasal crease, and a pale or blue/boggy wet appearance to the nasal mucosa if the patient is seen at a time when they have symptoms (whereas may look normal if asymptomatic).

Non-allergic rhinitis

Non-allergic rhinitis refers to a number of types of rhinitis. It can be more severe and difficult to treat than the symptoms of allergic rhinitis. The inflammatory non-allergic form is also commonly associated with asthma. An important phenotype is the patient who presents with late onset asthma with or without aspirin sensitivity, associated nasal polyps, and reduced smell and taste. Some serious systemic conditions (e.g. Wegener’s granulomatosis, Churg-Strauss syndrome) can present as difficult rhinitis and referral should therefore be considered (see Figure 1).1,11 Hypothyroidism can present with nasal obstruction, and excess oestrogen (resulting from pregnancy or use of oral contraceptives) is also associated with rhinitis. Overuse of topical nasal decongestant sprays, antihypertensive therapy, and alpha blockers can cause a chronically blocked nose. A trial of therapy with intranasal steroids is worthwhile as some cases of non-allergic rhinitis can be eosinophilic. Possible causes and triggers of non-allergic rhinitis are listed in Table 2.1

Infective causes of rhinitis

If rhinitis symptoms are associated with thick, green nasal secretions, it may be a sign of infection by agents, such as cold viruses and bacteria, for example Streptococcus and Haemophilus.1

Investigations

Healthcare professionals should take a detailed history and perform a nasal examination with an otoscope to help differentiate between allergic, non-allergic, and infective rhinitis, and to identify potential triggers and co-morbidities. Assessment findings will steer treatment in primary care, determine the need for further investigation, or indicate if the patient should be referred to an allergy clinic or the ear, nose, and throat (ENT) department (see Figure 1,below).1

The guideline from BSACI recommends that skin prick tests are used routinely in the secondary care setting to confirm or exclude underlying IgE-sensitivity to common aeroallergens (atopy) and provide objective information to support the clinical history concerning an underlying allergic basis. If skin prick tests are not possible in primary care, serum-specific IgE may be requested.1

The following investigations may facilitate diagnosis:1

  • Full blood count, erythrocyte sedimentation rate, and differential white cell count
  • C-reactive protein, if there is suspicion of a chronic infection
  • Thyroid function tests
  • Sputum culture
  • Urine toxicology if there is a suspicion of cocaine abuse
  • Peak expiratory flow measurements and spirometry should be considered for all patients with anything more than mild intermittent rhinitis.

Management

Management options for rhinitis include:1

  • allergen and irritant identification and avoidance
  • pharmacological treatment
  • immunotherapy
  • surgery—rarely needed
  • patient education—this is vital.

Allergen identification/avoidance

The taking of a good allergy focused history and background knowledge of the patient’s circumstances in primary care may identify a likely allergen to which skin prick or blood IgE tests can be directed. Hay fever can often be diagnosed on history alone.1

Figure 1: Treatment of rhinitis1111

graph

*Check nasal inhalation technique and compliance INS=intranasal corticosteroids; SPT=skin prick test; RAST=radioallergosorbent test; QoL=Quality of Life; NSAID=non-steroidal anti-inflammatory drugs. Reproduced with kind permission from BSACI; https://www.guidelines.co.uk/bsaci/rhinitis

Pharmacotherapy

Simple saline sprays or douches can reduce symptoms by washing allergens, pollutants, and mediators out of the nose.1 This intervention alone may be all that is required in some patients while in others, it will need to be accompanied by one or more of the pharmacological therapies discussed below.

Topical intranasal corticosteroids

Topical corticosteroids are the single most effective treatment of allergic rhinitis, as shown by several meta-analyses, and are indicated for individuals with persistent moderate to severe symptoms, and those with mild symptoms if they remain uncontrolled by antihistamines. Topical corticosteroids reduce all nasal symptoms, including nasal obstruction, and have also been shown to be beneficial for associated eye symptoms.1

 

Systemic absorption is very low with mometasone and fluticasone use—with good long-term safety data over 1 year— in children and adults, but high for betamethasone and dexamethasone. Although these agents may have a fast onset of action (within 6–8 hours), maximal improvement in symptoms may not occur for at least 2 weeks. Starting treatment 2 weeks before a known allergen season improves efficacy.1

Minor nose bleeding may occur in 5%–8% of patients using topical corticosteroids and may result in the need for discontinuation. This can be reduced by judicious use of the spray, aiming the nozzle towards the lateral wall of the nostril when placed just inside the nose (see Figure 2, see below). Very rarely hypothalamic-pituitary axis suppression may occur with long-term use and the BSACI guideline advises the monitoring of growth in children.1

Raised intra-ocular pressure has been described with the use of intranasal corticosteroids, and patients with a history of glaucoma should be monitored more closely.1

Table 2: Examples of presentation and causes of non-allergic rhinitis1
Type of rhinitis Example triggers
Drugs ACE inhibitors
Cocaine
Hormonal Pregnancy
Hypothyroidism
Contraceptive pill
Food Alcohol
Atrophic Trauma
Surgery
Radiation
Systemic/inflammatory Rheumatoid arthritis
Systmic lupus erythematous
Malignancy Squamous cell
Melanoma
Structural Nasal septal deviation
ACE=angiotensin-converting enzyme
Reproduced with kind permission from BSACI. Scadding G, Durham, S, Mirakian R et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy 2008; 38 (1): 19–42.

 

Antihistamines

Antihistamines are useful for mild symptoms, either intermittent or persistent. In the latter case, regular daily use is advisable. Antihistamines are active against sneezing, rhinorrhoea, and nasal itch, but are inferior to nasal corticosteroids in reducing nasal obstruction.1

Most second-generation oral antihistamines (loratidine, cetirizine, fexofenadine, desloratidine, levocetirizine, mizolastine, and rupatadine) reduce symptoms within 1 hour and are used once daily. The exception is acrivastine, which has a rapid onset of action, but lasts only 8 hours. Azelastine is a topical nasal antihistamine, which has fast onset of action (within 15 minutes). This therapy can result in minor adverse effects of local irritation and taste disturbance.

First-generation antihistamines such as chlorphenamine can cause sedation and reduced work and school performance and should therefore be avoided. In contrast, second-generation antihistamines, especially fexofenadine, have a very low potential for sedation.1 There are few major drug interactions with both first- and second-generation drugs. Grapefruit impairs fexofenadine absorption and this fruit should be avoided if taking this drug.

Combination therapy

If symptoms of rhinitis persist despite the use of antihistamines or topical intranasal corticosteroids alone, it is important to review the diagnosis, check patient compliance with treatment, and nasal spray technique. If the response remains poor then most practitioners would recommend combined treatment with both a non-sedating antihistamine and a topical nasal corticosteroid.

Other treatment options

Other treatment options for rhinitis include the following:1

  • Short-term use (i.e. <10 days) of an intranasal decongestant for nasal blockage (e.g. ephedrine, xylometazoline, or oxymetazoline) may be beneficial. Regular prolonged use of topical decongestants leads to tachyphylaxis and chronic nasal obstruction and should be avoided. Oral decongestants are not recommended because of poor efficacy and adverse effects
  • Anti-leukotrienes have some benefit, particularly in patients with co-morbid asthma. They are less effective than topical steroids
  • Topical anticholinergic preparations such as ipratropium bromide may be beneficial in reducing rhinorrhoea, particularly in the treatment of autonomic (previously called vasomotor) or allergic rhinitis
  • Topical sodium cromoglicate is effective but less so than topical corticosteroids and has the disadvantage of requiring several (3–4) doses daily. It retains a place in treatment of small children
  • Systemic corticosteroids should rarely be used, but have a role in severe nasal obstruction as short-term rescue, particularly for important life events. The guideline recommends 0.5 mg/kg orally for 5–10 days in combination with a topical nasal corticosteroid, taken in the morning with food
  • Injectable corticosteroids—injected preparations are not recommended except under exceptional circumstances. Compared with other available treatments, the risk– benefit profile for intramuscular corticosteroids is poor
  • Immunotherapy is the only treatment able to alter disease course and may prevent development of asthma. Initially performed by subcutaneous injection, the recent confirmation of the efficacy of sublingual immunotherapy has opened this avenue of therapy to a wider patient group. Immunotherapy is based on a 3-year programme of treatment and depending on the allergen used involves subcutaneous injections every 4–6 weeks, 4–9 pre-seasonal injections or a daily sublingual tablet. Chronic asthma is a contraindication and systemic reactions including urticaria, angio-oedema, asthma, and anaphylaxis can occur. For these reasons and also to ensure appropriate targeting of treatment to those individuals most likely to benefit, provision of immunotherapy is restricted to specialist allergy clinics. Although standard subcutaneous immunotherapy is widely available, only a few regions offer sublingual immunotherapy. This is difficult to explain as overall NHS costs are lower for sublingual immunotherapy because although initiated and supervised by an allergy clinic the patient does not require frequent treatment visits. This treatment is safe and effective when undertaken in selected individuals.12

Treatment in pregnancy

Pregnancy-associated rhinitis is self-limiting and treatment should only be initiated if the benefit of treatment outweighs even theoretical risk to the foetus. Saline nasal douching may be beneficial. Intranasal corticosteroids such as beclomethasone, fluticasone, and budesonide have been used widely by pregnant women with allergic rhinitis, as have antihistamines such as chlorphenamine, loratidine, and cetirizine. The guideline advises against the use of decongestants because of the potential for teratogenic effects (e.g. with pseudoephedrine). Immunotherapy should not be initiated in pregnancy, but can be continued.1

Treatment in children

Therapy for children includes antihistamines and nasal corticosteroids. Growth monitoring and a preparation with the lowest systemic bioavailability (fluticasone or mometasone) at the lowest dose for effective symptom control may be required if the child requires long-term treatment.1

Treatment failure

Approximately 20% of patients with rhinitis will experience treatment failure.14 This should prompt a check for compliance and, if necessary, referral to either an allergy clinic or ear, nose, and throat department.11

Referral

A map of UK allergy clinics can be found on the BSACI website (www.bsaci.org).13 Patients should be referred to an allergy clinic under the following circumstances:11

  • Inadequate control of symptoms
  • Recurrent nasal polyps
  • The patient is systemically unwell as a result of rhinitis
  • Need for allergen or trigger identification or diagnosis
  • Need to consider desensitisation
  • Presence of multisystem allergy (e.g. rhinitis with asthma, eczema, or food allergy)
  • Occupational rhinitis.

Referral to an ENT clinic should be made if there is/are:11

  • evidence of nasal crusting or bleeding from the nostrils, which may be a sign of systemic disorders such as sarcoidosis or Wegener’s granulomatosis—for example, blood-stained discharge, crusting high in the nasal cavity, or nasal collapse
  • unilateral symptoms and signs, such as nasal obstruction (which may be due to a nasal tumour), nasal perforation, or ulceration—these warrant urgent ENT referral
  • the presence of thick, green nasal secretions, suggesting an acute or recurrent infective rhinosinusitis
  • periorbital cellulitis—this warrants urgent ENT referral.
Figure 3: Correct procedure for the application of nasal sprays1

1. Shake bottle well

2. Look down

3. Using RIGHT hand for LEFT nostril put nozzle just inside nose aiming towards outside wall

4. Squirt once or twice (2 different directions)

5. Change hands and repeat for other side

6. DO NOT SNIFF HARD

Figure 3
Reproduced with kind permission from BSACI. Scadding G, Durham, S, Mirakian R et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy 2008; 38 (1): 19–42.

Education and prevention

The BSACI guideline emphasises the importance of allergy education, particularly with regard to the negative effect rhinitis may have on quality of life. The patient should be provided with information about potential complications. A review of drug therapy should be carried out to assess efficacy of and compliance with treatment, and this should also include an assessment of spray technique.16

There is a lack of evidence to recommend the use of mite-proof bed covers as a single intervention in sensitised patients. However, multiple measures to reduce house dust mite exposure, including the use of mite-proof bed covers, hot washing bed linen, removing soft toys, and so on, are more likely to be successful.16

A number of pollen avoidance measures, such as using nasal filters, wearing wraparound glasses, and minimising early morning and evening outdoor activity are sensible, although not always practical. Occupational rhinitis is considered a risk factor for occupational asthma and usually predates the onset of asthma. Primary prevention, particularly through the use of non-powdered or non-latex gloves, and avoidance of other occupational allergens known to cause allergic sensitisation, is particularly relevant in the workplace (see Table 1, see below).15

Implications for primary care

If primary care is provided with training and education, skin prick testing for aeroallergens can be offered in the community. Skin prick testing should only be performed by those skilled in the procedure and under conditions where an anaphylactic reaction can be managed. The Guideline Development Group for the NICE guideline on food allergy in children felt that skin prick testing could be performed in the community where facilities are the same as for routine vaccinations.16 Skin prick testing is not advisable outside specialist allergy clinics if the patient has a history of anaphylaxis.

Injectable adrenaline, IV hydrocortisone, antihistamine and nebulised beta2 agonist should be made available although they are often not needed. Systemic reactions to skin prick testing for airborne allergens are rare.

The importance of a close collaboration between primary care and allergy specialists is important, particularly in the interpretation of skin prick testing.

Local referral pathways are for the handling of patients who have not responded to treatment or when co-morbidities complicate management.

Barriers to implementation and suggested solutions

Allergy care is low on the NHS priority list, resulting in fragmented care and this, combined with few specialists and poor education in primary care, has led to an unmet need.17 The new Health and Social Care Act 2012 has an emphasis on integrated care. Good quality care of patients with allergy in the primary care setting, and closer liaison with pharmacists and referral of selected patients, would lead to better outcomes.

Primary care is ideally placed to manage rhinitis, and supporting and strengthening this role with education and training would be of benefit.18 The major problems are lack of consideration of rhinitis as a diagnosis and of under-treatment, often with antihistamines, when nasal corticosteroids would be more effective.

Rhinitis has been included as a research priority by the international primary care respiratory group. A recurring theme is the need for simple tools enabling diagnosis and assessment in community settings.19

For guidelines to be effective and implemented, GPs need to become more involved in guideline development.20 Some primary care groups have written their own summaries of secondary care guidelines.21 A recent advance has been the Royal College of Paediatrics and Child Health pathways, which include the management of rhinitis.22

Currently, rhinitis is not included in the quality and outcomes framework (QOF) points or in the new quality standards library. If rhinitis was included in QOF it could be combined under the asthma heading or template as part of asthma review and this may benefit control of asthma patients. Good asthma control is particularly important in patients with co-existing food allergy and these patients could be flagged as part of review.

Community pharmacists could play an important role in teaching nasal spray technique and in an informed discussion of antihistamines. Good liaison with community pharmacists and involving them in regional allergy networks and teaching programs could be of benefit.

Prescribing restrictions

Local prescribing restrictions may result in a reduced formulary or non-funding of medications for rhinitis. Patients may therefore feel discouraged from seeing their GP. The cost and availability of the medications to the patient should be considered in the light of long term effects on quality of life, work/school performance, and the likelihood of progression to asthma. This is particularly relevant to immunotherapy, with its potential to alter disease course.

Summary

Rhinitis can be subdivided into allergic, non-allergic, or infective subtypes, and correct diagnosis and compliance review is particularly important in patients whose rhinitis has proved refractory to standard therapy. Rhinitis often remains unrecognised, particularly when symptoms accompany co-morbid conditions such as asthma or sinusitis. Primary care has an important role in the identification and management of rhinitis, and the new clinical commissioning groups may provide an opportunity for development of improved initial assessment and speedy referral pathways particularly to allergy and ENT services for the management of those with severe rhinitis in whom the diagnosis remains in doubt or who fail to respond to usual treatment.

GP commissioning take home messages can be found above. Key points are located above.

 

View the Guidelines summary of the BSACI guideline on Rhinitis management guidelines at: https://www.guidelines.co.uk/bsaci/rhinitis

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead
  • Commissioners should consider:
    • adapting the BSACI recommendations on treatment into a local care pathway for rhinitis
    • the BSACI recommendations for allergy testing and the best way to meet them locally and within available resources
  • Careful case selection through a care pathway and the possibility of a community based service outside of the PbR tariff may help make this more affordable.
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  2. Ryan D, Grant-Casey J, Scadding G et al.Management of allergic rhinitis in UK primary care: baseline audit. Prim Care Respir J 2005; 14 (4): 204–209.
  3. Kaiser H. Risk factors in allergy/asthma. Allergy Asthma Proc 2004; 25 (1): 7–10.
  4. Corren J, Manning B, Thompson S et al. Rhinitis therapy and the prevention of hospital care for asthma: a case-control study. J Allergy Clin Immunol 2004; 113 (3): 415–419.
  5. Rafi I, Nasser S. New BSACI guideline aids GPs to recognise subtypes of rhinitis. Guidelines in Practice 2008; 11 (4): 29–38. Available at: https://www.guidelinesinpractice.co.uk/apr_08_nasser_rhinitis_apr08
  6. Canonica G, Bousquet J, Mullol J et al. A survey of the burden of allergic rhinitis in Europe. Allergy 2007; 62 (Suppl 85): 17–25.
  7. Walker S, Khan-Wasti S, Fletcher M et al. Seasonal allergic rhinitis is associated with a detrimental effect on examination performance in United Kingdom teenagers: case-control study. J Allergy Clin Immunol 2007; 120 (2): 381–387.
  8. Blaiss M. Cognitive, social, and economic costs of allergic rhinitis. Allergy Asthma Proc 2000; 21 (1): 7–13.
  9. Maurer M, and Zuberbier T. Undertreatment of rhinitis symptoms in Europe: findings from a cross-sectional questionnaire survey. Allergy 2007; 62 (9): 1057–1063.
  10. Aberg N, Hesselmar B, Aberg B, Eriksson B. Increase of asthma, allergic rhinitis and eczema in Swedish schoolchildren between 1979 and 1991. Clin Exp Allergy 1995; 25 (9): 815–819.
  11. Standards of Care Committee, The British Society for Allergy and Clinical Immunology. Rhinitis management guidelines. In: Hayeem N, editor. Guidelines—summarising clinical guidelines for primary care. 46th ed. Berkhamsted: MGP Ltd; February 2012, pp: 367–372.
  12. Walker S, Durham S, Till S et al. Immunotherapy for allergic rhinitis. Clin Exp Allergy 2011; 41 (9): 1177–1200.
  13. Bousquet J, Bachert C, Canonica G et al. Unmet needs in severe chronic upper airway disease (SCUAD) J Allergy Clin Immunol 2009; 124 (3) 428–433.
  14. British Society for Allergy and Clinical Immunology website. Allergy clinics in the UK. www.bsaci.org/index.php?option=com_clinics&Itemid=26 (accessed 29 May 2012).
  15. Bousquet J, Khaltaev N, Cruz A et al; World Health Organization; GA2(2) LEN;AllerGen. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen). Allergy 2008; 63 (Suppl 86): 8–160.
  16. National Institute for Health and Care Excellence. Diagnosis and assessment of food allergy in children and young people in primary care and community settings. Clinical Guideline 116. London: NICE, 2011. Available at: www.nice.org.uk/guidance/CG116
  17. Royal College of Physicians. Allergy services: still not meeting the unmet need. London: RCP, 2010.
  18. Ryan D, van Weel C, Bousquet J et al. Primary care: the cornerstone of diagnosis of allergic rhinitis. Allergy 2008; 63 (8): 981–989.
  19. Pinnock H, Østrem A, Rodriguez M et al. Prioritising the respiratory research needs of primary care: the International Primary Care Respiratory Group (IPCRG) e-Delphi exercise. Prim Care Resp 2012; 21 (1): 19–27.
  20. Costa J, Bousquet, P, Ryan D et al. Guidelines for allergic rhinitis need to be used in primary care. Prim Care Resp J 2009; 18 (4): 250–257.
  21. Angier E, Willington J, Scadding G. et al. Management of allergic and non-allergic rhinitis: a primary care summary of the BSACI guideline. Prim Care Resp J 2010; 19 (3): 217–222.
  22. Royal College of Paediatrics and Child Health website. Care pathway for asthma and/or rhinitis. www.rcpch ac.uk/allergy/asthmarhinitis (accessed 29 May 2012). G