Professor Aziz Sheikh (left) and Dr Sangeeta Dhami discuss the problems surrounding the underdiagnosis of this common allergic condition and the role of the GP in its management
Allergic rhinitis is now one of the most common long-term conditions in the economically developed world, with 20% of the UK population estimated to have it.1 The morbidity caused by allergic rhinitis can be considerable; unfortunately, this is often underestimated both by the patient and by healthcare professionals.2
The Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) has published guidance on the management of rhinitis, and this is referred to throughout this article.3 This guideline makes it clear that rhinitis can be both allergic and non-allergic in origin; the focus of this article is on the allergic variety.
Definition and classification
Allergic rhinitis is characterised by a symptom complex, including one or more of the following:3
- nasal itch
- nasal congestion.
The contemporary classification of allergic rhinitis is based on the World Health Organization’s Allergic Rhinitis and its Impact on Asthma (ARIA) guideline,4 which divides allergic rhinitis into ‘persistent’ and ‘intermittent’ forms; in the UK, the latter is virtually synonymous with the previous classification of ‘seasonal’ disease (i.e. hay fever). ‘Persistent’ refers to symptoms occurring for 4 or more days a week for a minimum of 4 weeks at a time, whereas ‘intermittent’ indicates symptoms occurring for less than 4 days a week or lasting for less than 4 weeks at a time.3,4
This classification also focuses on the severity of the disease, which is divided into ‘mild’ and ‘moderate to severe’ disease. Overall, mild symptoms are those that do not interfere with everyday activities, whereas moderate to severe symptoms do have an impact on day-to-day life, resulting in one or more of: disturbed sleep, difficulties caused at work or school, and impairment of sport or leisure activities.3 This classification is important when considering treatment options.3,4
Recent estimates suggest that over 600 million people worldwide may experience allergic rhinitis, and that 1 in 5 Europeans may be affected by this condition.2,5 Allergic rhinitis is notoriously under recognised in UK practice, which contributes to the large discrepancy between the symptomatic and the clinically diagnosed prevalence of allergic rhinitis. This is further compounded by the lack of adequate coding used to record diagnoses in many GP surgeries, which, among other things, can make auditing standards of care very difficult.
Since allergy testing is very rarely undertaken in primary care, another cause of concern voiced by many allergists is that it is sometimes very difficult to establish clearly whether or not the rhinitis has an underlying allergic basis.6 Co-morbidity with other allergic conditions is also common, particularly with asthma where it is estimated that up to 76% of people with asthma also experience rhinitis.7
Establishing a diagnosis
There is a need for better recognition and diagnosis of allergic rhinitis. General practitioners need to be alert to this important condition and actively seek it, particularly when there:8
- is a family history of atopy, eczema, asthma, or allergic rhinitis
- is severe or poorly controlled asthma; allergic rhinitis may be an exacerbating factor
- are seasonal variations in nasal symptoms, or symptoms triggered on exposure to non-allergic stimuli such as cigarette smoke, perfumes, and pollution.
The BSACI guideline states that allergic rhinitis is diagnosed by patient history and examination backed up by specific allergy tests. Characteristic symptoms include itching of the nose, eyes, and throat, repetitive sneezing, and a runny or blocked nose.2 Post-nasal drip is also common and a chronic cough may result—this should not be mistaken for asthma.4 Generalised fatigue due to symptoms, and the resultant disturbed sleep, is often the factor that prompts the patient to consult a doctor as the condition begins to impact on daily performance. Milder symptoms are often left untreated, or self-treated with over-the-counter products, with varying degrees of success.9
Examination will often reveal a congested nasal mucosa and a nasal crease across the dorsum of the nose. Nasal polyps may be present.2,3 Swelling of the eyelids and hyperaemia may also be evident.3
Investigations are usually unnecessary and only conducted when there is diagnostic doubt. However, the BSACI guideline has recommended the use of skin prick testing to identify specific allergens, the avoidance of which may improve symptoms.3 Serum-specific IgE tests may be performed if skin prick tests are impractical to conduct in the GP surgery, although, unlike skin prick tests, these have the disadvantage of results not being immediately accessible.3 If testing is to be undertaken, it is important to be aware of the likely allergic triggers. In those experiencing intermittent symptoms, tree and grass pollens, moulds, weeds, and occupational aggravated triggers, such as solvents, should be considered. In contrast, persistent symptoms are often caused by house dust mites, cats, or dogs. Rarely provocation testing is required to confirm a diagnosis, but this would need to be undertaken in a specialist setting.
There is a useful section in the BSACI guideline that stresses the importance of education about rhinitis.3 Education should encompass both the patient and the carer, and include discussion of the impact of this condition on school/work performance, sleep, and the need for ongoing treatment.3
The BSACI guideline highlights the importance of evidence-based education on the use of effective forms of allergen avoidance.3 Identification of specific allergen triggers (e.g. cats), and their subsequent avoidance may result in marked improvement of symptoms. Evidence indicates that in those reacting to more ubiquitous triggers (e.g. house dust mite) allergen avoidance measures, such as the use of special bedding and wooden floors to replace carpeted surfaces, are typically not as effective.10
For individuals experiencing mild symptoms, the BSACI guideline recommends treating with a non-sedating antihistamine,3 and head-to-head studies have shown no significant difference between the types available.11 These second-generation antihistamines are designed to be non-sedating; however, there is evidence to suggest that drowsiness may still be a problem with some preparations in some people, and this needs to be considered, particularly when prescribing for those in safety critical jobs.12,13 Regular use of antihistamines is more effective than intermittent use.3 Unfortunately, some GPs are still prescribing sedating antihistamines such as chlorpheniramine, which can compound the drowsiness resulting from the allergic rhinitis.14
For people with moderate to severe symptoms, the BSACI guideline suggests starting with an intranasal steroid with limited systemic bioavailability, for example mometasone or fluticasone.3 Betamethasone and dexamethasone result in greater systemic absorption and should therefore only be considered for short-term use. Intranasal steroids are more effective if commenced pre-seasonally as this suppresses the underlying immune response. Poor response to treatment may be due to poor inhaler technique,3 but up to 7–14 days should be allowed for the treatment to take maximal effect. If there is no improvement then the two treatments should be combined (i.e. combined use of a single intranasal steroid and a single antihistamine). If adequate symptom control has still not been achieved, then referral to an allergy clinic for desensitisation therapy should be considered.15
Additional treatment options include use of intranasal antihistamines (e.g. azelastine). These have a fast onset of action, but only work locally and have no effect on allergic symptoms in other organs such as the eyes.3 Oral steroids can be used, but they are only indicated for use in extenuating circumstances. For example, poor exam performance has been shown to be associated with poorly controlled disease, and so rescue treatment with a short course of oral steroids may be indicated around exam times.3,14
Anti-leukotrienes (e.g. montelukast), are another treatment option,3 but it should be noted that in the UK these are currently licensed only for use in patients with both asthma and seasonal allergic rhinitis.16 Nasal steroid drops may also be used short term in those with severe respiratory obstruction; these need to be delivered in the head-upside-down position to ensure effective delivery.3
Sublingual immunotherapy is an important recent step forward in the treatment of individuals with severe hay fever (i.e. intermittent or seasonal allergic rhinitis). For those patients who do not achieve adequate symptom control with a combination of a single intranasal steroid and a single antihistamine, the availability of a once-daily sublingual tablet provides a welcome additional treatment option. This treatment is usually initiated by a specialist and then continued in a community setting. Evidence suggests that it is effective with minimal risk of serious side-effects, although local side-effects are not uncommon.17
Subcutaneous immunotherapy is a more effective treatment option still, which should be considered in those who fail to respond to sublingual immunotherapy. However, as this therapy is associated with the risk of more serious systemic side-effects including anaphylaxis, its administration is restricted to specialist settings in which resuscitative facilities are readily available.15
In the vast majority of cases, allergic rhinitis can be effectively managed in primary care. Central to this process is the need for a careful history and examination to identify the common symptom complex and signs characteristic of allergic rhinitis. Individuals with mild and intermittent disease may be effectively treated with non-sedating antihistamines, but those with more persistent or severe disease will need intranasal steroids as the mainstay of management. Sublingual or injection immunotherapies are effective treatment options in those with pollen allergy who fail to respond adequately to pharmacotherapy.
- The Health Committee. Health—Sixth Report. London: House of Commons, 2004.
- Ryan D, van Weel C, Bousquet J et al. Primary care: the cornerstone of diagnosis of allergic rhinitis. Allergy 2008; 63 (8): 981–989.
- 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.
- World Health Organization. Allergic rhinitis and its impact on asthma. Geneva (Switzerland): WHO, 2008.
- Maurer M, Zuberbier T. Undertreatment of rhinitis symptoms in Europe: findings from a cross sectional questionnaire survey. Allergy 2007: 62 (9): 1057–1063.
- Walker S, Morton C, Sheikh A. Diagnosing allergy in primary care: are the history and clinical examination sufficient? Prim Care Resp J 2006; 15 (4): 219–221.
- Walker S, Sheikh A. Self reported rhinitis is a significant problem for patients with asthma. Prim Care Respir J 2005; 14 (2): 83–87.
- Bauchau V, Durham S. Prevalence and rate of diagnosis of allergic rhinitis in Europe. Eur Resp J 2004; 24 (5): 758–764.
- Valovirta E, Ryan,D. Patient adherence to allergic rhinitis treatment: results from patient surveys. Medscape J Med 2008; 10 (10): 247.
- Sheikh A, Hurwitz B, Shehata Y. House dust mite avoidance measures for perennial allergic rhinitis. Cochrane Database Syst Rev 2007; 24 (1): CD001563.
- Sheikh A, Singh Panesar S, Dhami S. Seasonal allergic rhinitis. Clin Evid 2005; 14: 684–695.
- Mann R, Pearce G, Dunn N et al. Sedation with "non-sedating” antihistamines: four prescription-event monitoring studies in general practice. BMJ 2000; 320 (7243): 1184–1186.
- Layton D, Wilton L, Boshier A et al. Comparison of the risk of drowsiness and sedation between levocetirizine and desloratadine: a prescription-event monitoring study in England. Drug Saf 2006; 29 (10): 897–909.
- 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.
- Calderon M, Alves B, Jacobson M et al. Allergen injection immunotherapy for seasonal allergic rhinitis. Cochrane Database Syst Rev 2007; 24 (1):CD001936
- British National Formulary. BNF 57. London: Royal Pharmaceutical Society, 2009.
- Wilson D, Lima M, Durham S. Sublingual immunotherapy for allergic rhinitis: systematic review and meta-analysis. Allergy 2005; 60 (1): 4–12.G