an acute-phase response of sneezing will occur as a consequence of inflammatory mediators stimulating afferent nerve endings in the nose. An increase in nasal secretion resulting in rhinorrhoea follows shortly afterwards, usually peaking around fifteen to 20 minutes post allergen exposure. After six to twelve hours, a late-phase response characterised by nasal obstruction will dominate.1,5

Allergic rhinitis is also associated with the development of allergic conjunctivitis, eczema and asthma.3 Statistics show that 40 per cent of patients with allergic rhinitis will develop asthma.6

barrier balm around edge of nostrils to prevent allergens entering nose

• Use of saline nasal washes to remove pollen or allergens from the nasal cavity

• Keeping car windows shut when travelling

• Ensuring car air filters are regularly serviced where these are present4,5,8

If the causative allergen of perennial rhinitis is animal dander, the offending pet should be kept outside or excluded from certain parts of the house such as living areas and bedrooms.4

There The charity Allergy

UK has recently warned that those patients whose allergic rhinitis symptoms are not well controlled are up to three times more likely to develop asthma and the ineffective management of ‘serious’ allergic rhinitis, as defined by moderate- to-severe symptoms, is causing thousands of avoidable asthma-related emergency hospital admissions every year.1,7

This warning reinforces the

importance of effective management of this condition.

It is important to note that some medicines can produce drug-induced rhinitis and this should be considered when symptoms follow the start of treatment with certain drugs such as angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, chlorpromazine, aspirin and non- steroidal anti-inflammatory medicines. Rebound symptoms can also occur when stopping treatment with nasal decongestants.3

Management of allergic rhinitis is broadly divided into allergy avoidance and medical treatment.

ALLERGY AVOIDANCE Experts agree that allergen avoidance is fundamental to the management of allergic rhinitis.1

is to avoid the causative allergen. For those with pollen allergies, advice includes:

• Avoidance of exposure to open grassy spaces

• Monitoring pollen forecasts and staying indoors wherever possible when count is high (pollen counts are higher on warmer, dry days)

• Shower, wash hair and change clothes after arriving home on high pollen count days

• Applying an effective allergen

is limited evidence to recommend the use of acaricidal sprays and extensive bedroom-based environmental control programmes to reduce the symptoms of perennial rhinitis caused by house dust mites. Patients can be advised to use synthetic pillows and acrylic duvets, wash all bedding and furry toys at least once weekly at high temperatures and choose wooden or hard floor surfaces instead of carpets where possible. The isolated use of house dust mite impermeable bedding is unlikely to prove effective.3


The mainstay of OTC medicines used to treat the symptoms of allergic rhinitis are oral antihistamines and intranasal corticosteroids.

The basic principle

For patients suffering from occasional symptoms of allergic rhinitis where rhinorrhoea and sneezing are the main presenting symptoms, oral antihistamines are of value in providing symptomatic relief.10 A once-daily, non-sedating antihistamine (such as cetirizine or loratadine) is preferable. Although effective, the use of older first- generation sedating antihistamines isnot routinely recommended in this condition. From an adherence perspective, oral acrivastine would be a second line alternative owing to its three times daily dosage. Though currently licensed as a prescription- only-medicine in the UK, intranasal azelastine is an effective option with a rapid onset of action (approximately fifteen minutes).9

For the management of more frequent or persistent symptoms, and/or where nasal congestion is the main symptom, intranasal corticosteroids (such as fluticasone, beclometasone) offer a more effective treatment. They are significantly more effective than oral antihistamines in relieving nasal blockage and post-nasal

drip. However, as their effect is not immediate and maximum relief may take days or weeks to be seen, they are most effective if used for a couple of weeks before symptoms present.9 Patients should be counselled to ensure they have good nasal spray technique as failure to properly use these products will lead to ineffective management.

For the relief of moderate to severe seasonal and perennial rhinitis, if monotherapy with antihistamine or corticosteroid is inadequate, a prescription only intranasal spray combining a corticosteroid and antihistamine (fluticasone and azelastine) is also available as an effective treatment option.10

Compliance with therapies should always be checked before modifying treatment. Topical nasal decongestants can be considered for a maximum of seven days if nasal obstruction is particularly problematic – their use can allow improved penetration of intranasal corticosertiods.9,10

In severe cases where quality of life is impaired, a very short course (five-ten days) of oral steroids can be prescribed by a doctor. Under specialist supervision, immunotherapy is another type of prescription treatment used in the management of certain types of allergic rhinitis if symptoms are severe. This therapy aims to make the immune system less sensitive to an allergen by gradually introducing more and more of the allergen into the body (for example via tablets containing grass pollen).9

Once treatment has provided adequate control of symptoms, pharmacists should be advising patients to continue treatment until they are no longer likely to be exposed to the suspected allergen. For those allergic to:

• Tree pollens – treatment usually required from early spring to late spring

• Grass pollens – treatment usually required from late spring to early summer

• Weed pollens – treatment usually required from early spring to late autumn

• Mould spores – symptoms tend to peak in early autumn, but can present throughout the year, requiring ongoing treatment

• House dust mite and/or pets that

remain in the home – symptoms usually present throughout the year, requiring ongoing treatment.3

Patients who have recurrent episodes of allergic rhinitis controlled by intranasal corticosteroids should also be advised to restart their treatment at least seven days before re-exposure to allergens. If the time of re-exposure is uncertain, for example at the start of the pollen season, patients should start treatment several weeks before the most likely time of re-exposure.3

The ineffective treatment of allergic rhinitis is a major problem. Despite taking treatments, as many as 96 per cent of suffers remain symptomatic. A significant factor in ineffective management is non-adherence to treatment, with an estimated half of all sufferers failing to complete a course of treatment as prescribed. Other reasons include only taking treatment on days when there is a high pollen count, rather than everyday (for those suffering from seasonal allergic rhinitis). Additionally, poor inhalation technique for topical nasal steroids contributes to ineffective symptom control.1

Through effective

patient counselling and education, this is a key area in which we as pharmacists can make a significant difference. •


1. Allergy UK. One Airway, One Disease. files/assets/common/downloads/ One%20Airway%20One%20 Disease%20Report.pdf [Online] 2. Statista. Sales value of hayfever remedies in Great Britain from 2009 to 2016 statistics/5218 41/otc-hayfever-remedies- sales-value-great-britain/ [Online] 3. NICE Clinical Knowledge Summaries. Allergic Rhinitis. allergic-rhinitis [Online] 4. P. Rutter. Community Pharmacy: Symptoms, Diagnosis and Treatment 5. Patient. Allergic Rhinitis. http:// [Online]

6. Allergy UK. Allergy Statistics. https:// allergy-statistics [Online] 7. Allergy UK. https://www.allergyuk. org/news/latest-news/post/147-expert- report-reveals-underestimated-link- between-serious-hay-fever-and-asthma [Online]

8. Allergy UK. Hay Fever and Allergic Rhinitis. hayfever-and-allergic-rhinitis/hay-fever- and-allergic-rhinitis [Online] 9. NHS Inform Scotland. Allergic Rhinitis. illnesses-and-conditions/ears-nose-and- throat/allergic-rhinitis# [Online] 10. British National Formulary Issue 72 11. J Allergy Clin Immunol. 2008. The Diagnosis and Management of Rhinitis: an Updated Practice Parameter. http:// 6749(08)01123-8/fulltext [Online]

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