Allergic rhinitis is not only increasing in prevalence1,2 but also underestimated as a cause of suffering and impaired quality of life.3,4 It imposes restrictions on the physical, social and psychological aspects of patients' lives, and may have an impact on their schooling and occupation. Uncontrolled symptoms can contribute to learning problems and sleep disturbance.5,6
In addition, it is not always appreciated that rhinitis can have serious secondary effects,7 including sinusitis, otitis media, nasal polyposis and lower respiratory tract infection.
Its contribution to the deterioration of lower airway function in asthma is apparent and incompletely understood. Rhinitis is a risk factor for the development of asthma, and is also present in approximately 80% of people with asthma.
The treatment of rhinitis decreases the incidence of bronchial hypertrophy8 and chest symptoms.9
Many patients either do not seek treatment, or buy over-the-counter medications of varying degrees of suitability. Some of these (decongestants, sedating antihistamines) may worsen the patient's quality of life and contribute to symptomatology.
Allergic rhinitis forms a significant part of a GP's workload throughout the year, yet patient satisfaction with treatment is often low, especially in perennial allergic rhinitis.10
The British Society for Allergy and Clinical Immunology set up an ENT Special Interest Group, who in 1998 published the initial set of rhinitis management guidelines. These have now been revised and updated for the second time and are published this month. The aim is to improve the identification, diagnosis and management of rhinitis in primary care and to assist with appropriate referral to secondary care.
Increased appreciation of the pathophysiological mechanisms of rhinitis is leading to improvement in treatment. Newer treatments that have become available over the past few years include topical antihistamines, newer forms of immunotherapy, and leukotriene receptor antagonists. Appreciation of the anti-inflammatory effects of some antihistamines has also increased.
Detrimental effects of therapy, such as prolongation of the QT interval by terfenadine and astemizole and the demonstration of growth retardation in children on long-term beclometasone have necessitated reappraisal of the use of such drugs.
These guidelines also reflect the division employed in the new WHO guidelines Allergic Rhinitis and Its Impact on Asthma (to be published), in which rhinitis is classified as either intermittent or persistent rather than seasonal or perennial.
Pharmacotherapy recommendations have evidence levels of category A. For other recommendations the evidence is mainly from categories A and B.
If primary care practitioners could be persuaded to use the guidelines, particularly with respect to history and skin-prick testing (which could be the province of the practice nurse with extra allergy training obtainable from the National Asthma and Respiratory Training Centre), patients with allergic rhinitis are more likely to be identified early and be persuaded to undertake environmental control. It is hoped that this will not only reduce their rhinitis symptoms and the need for medication, but also reduce the likelihood of progression of disease.
Early immunotherapy in children with rhinitis has been shown to reduce the number who develop asthma. It is not yet known whether adequate rhinitis care with environmental control will prevent the development of asthma; this is an area in which further research is needed.
By promoting the use of the most appropriate pharmaceutical preparations for any given circumstance, and by notifying GPs of which patients need onward referral, the guidelines should ensure that best practice ensues. A recent trial11 confirmed that patients treated according to rhinitis guidelines were less symptomatic than those treated as their GPs saw fit.
To facilitate use of the guidelines, a double-sided A4 version containing a brief summary and treatment algorithm has also been produced (Figure 1, below) .
Also proposed is a rolling, good anti-allergy practice programme. This involves pre-audit with establishment of a baseline of present practice in primary care, analysis of the results, and the development of education packs with interested GPs. Following this, audit would be undertaken to assess the effect of these measures.
With 20% of young adults in the UK affected by allergic rhinitis, it is certainly time that some very effective intervention was put into practice.
|Figure 1: Front and back of the A4 summary of the British Society for Allergy and Clinical Immunology rhinitis management guidelines|
Copies of the guidelines can be obtained from the BSACI Secretariat, 66 Weston Park, Thames Ditton, Surrey, KT7 OHL (tel 020 8398 9240; fax 020 8398 2766; email firstname.lastname@example.org).
- Aberg N, Sundell J, Eriksson B et al. Prevalence of allergic diseases in school children in relation to family history, upper respiratory tract infections and residential characteristics. Allergy 1996; 51: 232-7.
- Sibbald B, Rink E, D'Souza M et al. Is the prevalence of atopy increasing? Br J Gen Pract 1990; 40: 338-40.
- Bousquet J, Bullinger M, Fayol C et al. Assessment of the quality of life in patients with perennial allergic rhinitis with the French version of the SF-36 Health Status Questionnaire. J Allergy Clin Immunol 1994: 94: 182-8.
- Spaeth J, Kilmex L, Mosges R et al. Sedation by allergic rhinitis is caused by the condition and not by the antihistamine treatment. Allergy 1996; 51: 903-6.
- Vuurman EF, Van Veggal LM, Utterwuk MM et al. Seasonal allergic rhinitis and antihistamine's effects on children's learning. Ann Allergy 1993; 71:185-9.
- Simons FE. Learning impairment and allergic rhinitis. Allergy Asthma Proc 1996; 17: 135-41.
- Jarikre LN, Ogisi FO. Nasal symptoms in bronchial asthma. East Afr Med J 1990; 67: 9-12.
- Aubier M, Levy J, Clerici C, Neukirch F, Herman D. Different effects of nasal and bronchial glucocorticosteroid administration on bronchial hyper-responsiveness in patients with allergic rhinitis. Am Rev Respir Dis 1992; 146: 122-6.
- Welsh P, Stricker WE, Chu-Pin C et al. Efficacy of beclomethasone nasal solution, flunisolide and cromolyn in relieving symptoms of ragweed allergy. Mayo Clin Proc 1987; 62: 125-34.
- Scadding GK, Richards DH, Price MJ et al. Patient and physician perspectives on the impact of management of perennial and seasonal rhinitis. Clin Otolaryngol 2000, in press.
- Bousquet J. Data presented at the European Allergy and Clinical Immunology Meeting, Lisbon, July 2000.