Dr Matthew Doyle revisits the BSACI guideline on allergic and non-allergic rhinitis and highlights the need for allergy testing by clinicians in primary care
R hinitis is a common, often self-limiting condition involving inflammation of the nasal mucosa and associated with nasal congestion, anterior and posterior rhinorrhoea, sneezing, and itching. In a significant number of patients, the symptoms are more severe, affecting quality of life, and school or work attendance, and there is an associated healthcare cost.
Management of rhinitis has been identified as sub-optimal,1 and the British Society for Allergy and Clinical Immunology (BSACI) guideline on the management of allergic and non-allergic rhinitis2 was produced in 2008 to help improve and standardise the care of patients with these conditions. Though it covers the full aetiology of rhinitis, the guideline’s primary focus is on those patients whose condition has an allergic cause.
The recommendations in the guideline remain current, and a recent review of allergic rhinitis in The Lancet reprinted its treatment algorithm. 3
Although the BSACI guideline2 is aimed principally at secondary/tertiary care clinicians, a review article published in the Primary Care Respiratory Journal in 2010 summarised the key points and how they apply to primary care.4
There are considerable difficulties for primary care in the assessment of patients with rhinitis. For the 20% of UK adults and children with allergic rhinitis,4 identification of the allergen can be helpful in guiding management. Skin prick testing (SPT) or blood immunoglobin E (IgE) tests can be used for this purpose. However, training for clinicians in skin prick testing, and availability of the test for patients, is relatively poor in UK primary care; also blood testing for specific IgE is often underused. The result is that diagnosis for allergic rhinitis is either made following secondary/tertiary care referral, or sometimes not at all.
Rhinitis is generally divided into the three categories of infective, allergic, and non-allergic rhinitis.
Most children and adults experience infective rhinitis (‘the common cold’) from time to time, with viruses being the most prominent organisms isolated (i.e. coronaviruses, rhinoviruses, respiratory syncytial virus [RSV], etc). It is estimated that school-age children will experience 6–8 episodes of these viral infections every 12 months.5 Management of the majority of these patients is likely to be supportive as the condition can be presumed to be self-limiting.
Bacterial super-infection is thought to occur in up to 2% of these cases,6 when symptoms are more likely to include nasal crusting, purulent discharge, and facial pain. Fungal infections are generally rare, but should be considered in immunosuppressed individuals with persistent symptoms.
The prevalence of allergic disease is increasing rapidly in the UK and its management remains under-resourced. It is estimated that 20% of the UK population is affected by allergic rhinitis.2 Similar data have suggested that in the USA, 10%–30% of the adult population and up to 40% of children are affected,7 with an annual economic burden of more than $10 billion.8
Increasingly, data suggest a link between rhinitis and asthma, with rhinitis identified as a risk factor for developing asthma (see Box 1). Effective treatment of rhinitis is also associated with benefits for asthma control.
Allergic rhinitis occurs when a sensitised individual is exposed to the allergen, and mast-cell histamine is released following crosslinking of IgE molecules bound to the mast cells. The allergens involved are generally airborne (aero-allergens).
Allergic rhinitis can be seasonal (e.g. when caused by pollens such as grasses and trees, or fungal spores such as Alternaria and Aspergillus) or perennial (e.g. when caused by house dust mite [HDM]) (see Box 2). Animal allergies (e.g. cat, dog, horse) are also commonly seen. Food allergens are less frequently implicated. In some cases, occupational exposure to dusts and chemicals can be the trigger.
Allergic rhinitis is more common in children and in those with a personal or family history of atopy.
Box 1: Rhinitis and asthma
- Asthma and rhinitis usually co-exist—up to 80% of patients with asthma have symptoms of rhinitis8,9
- Rhinitis is a risk factor for the development of asthma10
- Allergy to house dust mite and cat dander is a risk factor for both asthma and rhinitis11
- Patients with both viral and seasonal rhinitis have been shown to have periods of increased bronchial responsiveness12
- Patients with asthma and rhinitis who receive treatment for allergic rhinitis have a significantly lower risk of hospitalisations or attendance at A&E departments for asthma.13
Box 2: Which allergens to test for?
- Seasonal (intermittent) symptoms:
- trees (generally early spring)
- grasses (Timothy-grass in summer, ‘hay fever’)
- fungi/moulds such as Alternaria, Cladosporium, andAspergillus (autumn or perennial)
- Perennial (persistent) symptoms:
- house dust mite and specific pets
- Any triggers identified by the patient
- If patient is asthmatic, house dust mite should be one of the tests performed
- If occupational rhinitis or asthma is suspected, refer patient directly to specialist care for testing.
Non-allergic rhinitis is seen in patients with negative SPT or specific IgE testing. There are many possible causes, including:
- drugs, such as non-steroidal anti-inflammatory drugs (NSAIDs) and angiotensin-converting enzyme (ACE) inhibitors
- conditions such as hypothyroidism, cystic fibrosis, Wegener’s granulomatosis, and Churg–Strauss syndrome.
It should also be noted that hormonal rhinitis can occur in at least 20% of pregnant women.2
History and diagnosis
History, as always, is extremely helpful in identifying whether a patient is suffering from allergic disease. The history should include the symptoms, and the clinician should watch out for particular pointers (green discharge suggesting infection; seasonality of symptoms, atopic family history, prior diagnosis suggesting allergy; other systemic disease, medication history, etc [see Box 3]).2
Box 3: Allergic rhinitis and the 10-minute appointment
- allergic—yellow/clear discharge, sneezing, itching nose/palate, associated watering/itchy eyes, cough, wheeze and shortness of breath, seasonality, atopic patient
- infective—green/yellow discharge, cough, sore throat, short length of history, no seasonality
- red flags—blood-stained mucus/bleeding, unilateral nasal obstruction (foreign body, etc), nasal pain, nasal deformity, other associated diseases
- seasonal (intermittent)—grass pollens (spring to summer), tree pollens (early spring), fungal spores (autumn)
- perennial (persistent)—house dust mite, animals/pets, fungal spores, multiple pollen/fungal sensitivities
- at home—house dust mite, animals/pets
- at work—occupational exposures
- symptoms improve while on holiday abroad
- Ask about:
- pets at home, exposures at work, personal or family atopic history, snoring, triggers the patient is aware of
- Nasal crease at junction of lower/middle third of nose from rubbing/pushing nose up (the ‘allergic salute’), polyps, wheeze in chest, foreign body, nasal deformity.
Should I perform allergy testing?
Skin prick testing is the standard method for assessing sensitivity to allergen and its use is advocated in the BSACI guideline in all patients. Availability of SPT in primary care is generally limited and most patients are referred to secondary care for assessment or remain untested. The BSACI guideline suggests that specific IgE testing may be used when SPT is unavailable.
Most local pathology services will offer blood testing of specific IgE to allergens and will be able to advise on which panels of allergens may be available (aero-allergen panel, food panel, etc) if there is confusion over which allergens to test for. Such blood tests correlate well with SPT (although SPT may be more sensitive for inhaled allergens, such as cat and pollens). It is important to understand that positive results indicate sensitisation to an allergen rather than confirming allergy per se (i.e. patients may be sensitised but experience no symptoms or disease). Negative tests should not be considered as excluding allergy and results should always be interpreted in the context of the patient’s history and presentation.
Elevated levels of total IgE are not usually helpful. There are also many available IgG tests, which patients may access (York Test). These are not considered helpful in diagnosing allergy.14
In a significant proportion of patients, treatment with antihistamines and intranasal corticosteroids (INS) will be effective in controlling symptoms. General practitioners may ask themselves, ‘Will I change this patient’s management by testing for allergens?’ In fact, there are several situations where skin prick and specific IgE testing may be helpful in primary care, for example to help:
- confirm or exclude allergy as a cause of symptoms, preventing unnecessary or inappropriate treatment
- confirm or exclude a pet as a trigger and hence inform what avoidance or prophylactic measures might be taken
- advise patients when to start and stop their treatment in seasonal rhinitis
- identify patients sensitised to HDM who are at risk of perennial symptoms and asthma.
It is important that the results of such tests are interpreted in the context of the patient’s history.
Treatment of allergic rhinitis
Mainstream treatment of allergic rhinitis consists of allergen avoidance strategies, and nasal rinses and drops.2
Allergen avoidance may be difficult (especially the avoidance of aero-allergens, although nasal filters are available), or unwelcome to patients or carers (for example, where the cause of the allergy is a pet). Temporary pet removal has not been shown to be effective.
Single measures for HDM avoidance (bedding covers) have not been found to be effective, although multiple measures combined may have benefit.15
Nasal rinses and drops
Nasal rinses and drops are commonly used across Europe. Saline douching is a safe and effective method of reducing symptoms of allergic rhinitis. Saline drops are also effective in allergic conjunctivitis.16
Oral or topical antihistamines should be the first-line treatment for mild symptoms. Non-sedating antihistamines (e.g. cetirizine, loratidine, fexofenadine) are generally better tolerated than the sedating antihistamines. Patients should be advised to take antihistamines regularly rather than as required.2
For moderate or severe symptoms, or where symptom control is not achieved with antihistamines, intranasal corticosteroid sprays or drops should be prescribed. Correct technique when adminstering the INS is important, but frequently not discussed with patients at the time of prescription (see Figure 2). Patients should be advised that maximal effect may not be seen until 2 weeks after starting use of INS sprays or drops.2
Most INS are equally effective, and long-term growth studies of children with budesonide, fluticasone, and mometasone (but not beclometasone17) are encouraging.18 Systemic absorption is negligible for fluticasone and mometasone, high for betamethasone and dexamethasone, and modest for the remainder.2
Oral corticosteroids are rarely indicated. An important event such as a wedding or examination may suggest short-term use, always in conjunction with topical INS. Intramuscular injections of steroid are not recommended, as the risk–benefit profile is poor in comparison with other treatments.19
Additional treatments include ipratropium for watery rhinorrhoea, and anti-leukotrienes (such as montelukast) for persistent rhinitis in patients with asthma.
When to refer
The following groups of patients should be referred for secondary assessment:
- all patients with suspected occupational rhinitis and/or asthma
- all children with suspected food allergy and asthma
- patients who fail to respond to the regular treatment algorithm, for whom immunotherapy may be available
- patients with whom there is diagnostic uncertainty, or ‘red flags’ in the history and/or examination.
Challenges facing primary care
Compared with other European countries, there is still a lack of specialist allergic services in the UK, so accessing appropriate care in some areas is difficult. Local commissioning groups can help in identifying services nearby. The BSACI website (www.bsaci.org) has an up-to-date list of specialist clinics.
Guidance written for primary care regarding allergic disease has until recently been scarce, and there have been low levels of primary care involvement in the development of such guidance. The NICE guidelines regarding food allergy20 and anaphylaxis21 both had primary care representation and have detailed the importance of taking an allergy focused history in primary care. They also stress the need for adequate specialist services across the UK.
Training to perform and interpret allergy tests in primary care is uncommon in vocational training schemes, partly because of a lack of specialist availability. Patients therefore sometimes seek alternative testing methods, leading to confusion and difficulty for both patients and GPs. Increasingly, there are online and traditional qualifications available for GPs who wish to improve their knowledge of allergic medicine. A list of these can be found on the BSACI website.22
Useful patient information and resources can be found on the Allergy UK website.23
The BSACI guideline remains current and evidence based. While the guideline is primarily aimed at specialist care, the majority of patients with rhinitis present initially to their GP who has a key role in identifying and initiating appropriate testing and treatment.
- The BSACI guideline recommends a far greater role for allergy testing than is currently provided in the majority of clinical practice
- In the current resource-restricted environment, CCGs will need to balance these recommendations against other commissioning priorities
- CCGs should investigate the availability of serum-specific IgE testing at local laboratories, as this is likely to be a more realistic and cost-efficient method of ensuring allergy testing than training busy GPs in skin prick testing
- CCGs should ensure they have access to a specialist allergy service for complex or more severe cases
- Once allergy services are commissioned, CCGs should ensure clear local care pathways are available to primary care to make the most efficient use of these services
- The link between allergic rhinitis and asthma is significant;9 CCGs could encourage practices to specifically address rhinitis symptoms in annual asthma reviews, as effective rhinitis treatment could improve asthma control for patients and reduce expenditure on asthma medication and emergency admissions.9
BSACI=British Society for Allergy & Clinical Immunology; CCG=clinical commissioning group; IgE=immunoglobin E
- Ryan D, Grant-Casey J, Scadding G et al. Management of allergic rhinitis in UK primary care: baseline audit. Prim Care Resp J 2005; 14 (4): 204–209.
- 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.
- Greiner A, Hellings P, Rotiroti G et al. Allergic Rhinitis. Lancet 2011; 378 (9809): 2112–2122.
- Angier E, Willington J, Scadding G et al. Management of allergic rhinitis and non-allergic rhinitis: a primary care summary of the BSACI guideline. Prim Care Resp J 2010; 19 (3): 217–222.
- Ramadan H. Paediatric sinusitis: update. J Otolaryngol 2005; 34 Suppl 1: S14–S17.
- Gwaltney J Jr. Acute community acquired bacterial sinusitis: to treat or not to treat. Can Respir J 1999; 6 Suppl A: 46A–50A.
- Tran N, Vickery J, Blaiss M. Management of rhinitis: allergic and non-allergic. Allergy Asthma Immunol Res 2011; 3 (3): 148–156.
- Allergic rhinitis: common, costly and neglected. Lancet 2008; 371 (9630): 2057 (editorial).
- Bourdin A, Gras D, Vachier I, Chanez P. Upper airway 1: Allergic rhinitis and asthma: united disease through epithelial cells. Thorax 2009; 64: 999–1004.
- Wright A, Holberg C, Martinez F et al. Epidemiology of physician-discovered allergic rhinitis in childhood. Pediatrics 1994; 94 (6 Pt 1): 895–901.
- Sears M, Herbison G, Holdaway M et al. The relative risks of sensitivity to grass pollen, house dust mite and cat dander in the development of childhood asthma. Clin Exp Allergy 1989; 19 (4): 419–424.
- Gerblich A, Schwartz H, Chester E. Seasonal variation of airway function in allergic rhinitis. J Allergy Clin Immunol 1986; 77 (5): 676–681.
- 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.
- Scott H, Sicherer, M, Robert A et al. Allergy testing in childhood: using allergen-specific IgE tests. Pediatrics 2012; 129 (1): 193–197.
- Nurmatov U, van Schayk C, Hurwitz B, Sheikh A. House dust mite avoidance measures for perennial allergic rhinitis. Cochrane Database Syst Rev 2001; CD001563.
- Garavello W, Romagnoli M, Sordo L et al. Hypersaline nasal irrigation in children with symptomatic seasonal allergic rhinitis: a randomized study. Pediatr Allergy Immunol 2003; 14 (2): 140–143.
- Skoner D, Rachelefsky G, Metlzer E et al. Detection of growth suppression in children during treatment with intranasal beclometasone dipropionate. Pediatrics 2000; 105 (2): E23.
- Allen D. Systemic effects of intranasal steroids: an endocrinologist’s perspective. J Allergy Clin Immunol 2000; 106 (4 Suppl): S179–S190.
- Nasser S, Ewan P. Lesson of the week: depot corticosteroid treatment for hay fever causing avascular necrosis of both hips. BMJ 2001; 322 (7302): 1589–1591.
- NICE. 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/cg116
- NICE. Anaphylaxis: assessment to confirm an anaphylactic episode and the decision to refer after emergency treatment for a suspected anaphylactic episode. Clinical Guideline 134. London: NICE, 2011. www.nice.org.uk/cg134
- BSACI website. Postgraduate Courses in Allergy and Immunology 2012/13. www.bsaci.org/meetings-and-events/post-graduate-courses (accessed 9 May 2013).
- Allergy UK website. Hay fever and allergic rhinitis. www.allergyuk.org/hayfever-and-allergic-rhinitis/hay-fever-and-allergic-rhinitis (accessed 9 May 2013). G