In most cases hayfever can be managed successfully in community pharmacy through self-management advice and by offering appropriate treatments to manage symptoms

Allergic rhinitis is common and it affects around a quarter of all adults in the UK. Prevalence continues to increase. Seasonal allergic rhinitis, more commonly known as hayfever, is caused by both genetic and environmental factors with allergens such as grass and tree pollens causing symptoms.

Hayfever is the result of an IgE-mediated inflammatory disorder affecting the nasal mucosa when it is exposed and sensitised to allergens. This triggers the release of inflammatory mediators, including histamine, resulting in an individual having symptoms of sneezing, nasal itching and discharge, and congestion.

Symptoms usually occur at the same time each year in response to a seasonal allergen. However, an individual’s symptoms may change from year to year as the duration and intensity of the pollinating season can vary with trees pollinating in spring, grasses at the end of spring into summer and weeds from early spring to late autumn. Due to seasonal variability it may initially be difficult to identify the allergen responsible for symptoms.

Sneezing and nasal itching, discharge and congestion are the symptoms likely to be present, affecting both nostrils and occurring after a couple of minutes of allergen exposure. Eye symptoms such as itching, redness and watering can occur along with other symptoms such as post-nasal drip, cough, snoring and halitosis due to nasal congestion. The severity of symptoms varies from person to person, ranging from mild symptoms that are not troublesome and do not impact quality of life, to moderate or severe symptoms that can interfere with sleep and activities throughout the day.

Allergic rhinitis can impair quality of life, especially during the peak pollen season, affecting work, school and social lives due to disturbed sleep and reduced concentration. Sleeping problems occur in up to 57 per cent of adult patients and up to 88 per cent of children, leading to daytime fatigue, drowsiness and decreased cognitive function.

Allergies and asthma

Allergy is the cause of asthma in about 80 per cent of cases. Younger individuals with asthma have a higher incidence of allergies. There are further risks for people with allergies that sinusitis and nasal polyps may develop.

Allergic rhinitis is usually a life-long condition, so individuals need to manage it appropriately. It should be noted that some medicines, such as alpha-blockers, ACE inhibitors and NSAIDs, can cause or aggravate rhinitis symptoms. This should be considered when managing patients.

How to manage allergic rhinitis?

It is important to know what the allergen is so it can be avoided. For example, if the trigger is grass pollen, sufferers should be advised to:

Not expose themselves to pollen when the pollen count is high by:

• Reviewing the pollen forecast daily. Pollen is normally high in the early morning when it is being released and in the early evening when the weather begins to cool and the pollen falls to the ground. Hot, dry days normally have higher pollen forecasts and wet days lower pollen counts
• Avoiding walking in grassy, open spaces, particularly during the early morning and evening and when grass is being cut
• Not drying washing outside
• Keeping windows shut at home, work and in the car
• Wearing wraparound sunglasses when outside
• Planning holidays that avoid the pollen season.

Where exposure has occurred to:

• Wash their hair and clothes following high pollen exposure.

NICE advises the use of nasal irrigation with saline to remove any pollen. Rinsing the nasal cavity with a spray/pump/squirt bottle may be an option to remove the allergen.

Self-management strategies and drug treatment options will depend on the severity of symptoms.

Mild-to-moderate intermittent or mild persistent symptoms

• First-line management: An intranasal antihistamine ‘as required’ or a non-sedating oral antihistamine (e.g. loratadine, cetirizine) for mild symptoms, depending on the person’s age and personal preference. Intranasal antihistamines are generally superior to oral preparations as they have a greater effect in reducing rhinitis symptoms and nasal obstruction. Additionally, intranasal antihistamines such as azelastine have a faster onset of action for controlling breakthrough symptoms.

Short-term use of a decongestant or an intranasal corticosteroid are also options, the latter if moderate-to-severe intermittent nasal symptoms such as sneezing, rhinorrhoea, obstruction and itch predominate. Note that a new POM to P switch has recently been launched, Clarinaze Allergy Control (mometasone furoate 0.05%)

• Second-line management: An intranasal chromone such as sodium cromoglicate should be used ‘as needed’ up to four times a day. Chromones are less effective than intranasal antihistamines and may be weakly effective for rhinitis symptoms with some effect on nasal obstruction. The frequent application required may reduce adherence with this medication. Chromones are useful for people with limited drug treatment options, such as in pregnancy or breastfeeding.

It is important that patients know how to use their intranasal spray or drops correctly to avoid treatment failure, so advice should be given to ensure they are competent in using their medicine appropriately.

Moderate-to-severe persistent symptoms

Intranasal corticosteroids, such as mometasone furoate, fluticasone furoate or fluticasone propionate, should be used first-line on a regular basis over the time of allergen exposure. They all have comparable efficacy, with negligible systemic absorption, reducing the likelihood of adverse effects. Patients should be advised on this to enhance adherence.

Patients should also be advised that the initial onset of action will take six to eight hours after the first dose and the medicine needs to be taken regularly so the maximal effect can occur, although this may not be seen for two weeks. It is important that the patient does not exceed the manufacturer’s recommended dose as there is no evidence of additional benefit.

Effective treatment

If the medicine provides adequate symptom control, the patient should continue treatment for the duration of time they are exposed to the allergen. Where exposure to the allergen is likely and the patient has previously used an intranasal corticosteroid, this should be started two weeks before re-exposure to avoid symptoms of allergic rhinitis.

Note that where the pollination season varies and is likely to occur earlier than thought, an intranasal corticosteroid should be used several weeks beforehand to reduce the likelihood of allergen exposure and associated symptoms.

Ineffective treatment

If the patient still has symptoms after two weeks of taking antihistamines and four weeks of using intranasal corticosteroids and self-management strategies, he/she should be reviewed. Intranasal corticosteroids are more effective than oral antihistamines in children and adults with seasonal and persistent symptoms. Monotherapy with intranasal corticosteroids provides a greater reduction in seasonal and persistent symptoms than intranasal antihistamines.

The cause of treatment failure should be assessed to see if the patient is exposed to the allergen more than is necessary or has an issue with the medicine, such as not taking it as intended or not using the correct technique for nasal sprays or drops.

Stepping up the treatment may be an option to reduce symptoms when an individual is using regular intranasal corticosteroids. The symptoms causing the problems should be addressed with ‘add in’ therapies (see Table 1). Some of these preparations are not available over the counter, so the patient should be referred to their GP.

After all the treatment options have been explored in primary care, some patients may require referral to an allergy specialist who will conduct allergy testing to identify the allergen and consider the possibility of immunotherapy treatment, a specialist treatment that is only appropriate in individuals with persistent symptoms. This treatment can modify disease progression and prevent children in developing asthma in addition to providing long-term remission.

Treatment round-up (excluding intranasal corticosteroids; see previous sections)

Intranasal antihistamines: Azelastine hydrochloride intranasal spray is the only intranasal antihistamine that is licensed in the UK for the treatment of allergic rhinitis. It is used in both nostrils as a twice daily dosage in those over six years of age. There are no contraindications or cautions for the intranasal spray and the adverse effect of having a bitter taste is due to incorrect use, so guidance on usage should be given. Irritation of the nasal mucosa in addition to hypersensitivity reactions can occur.

Oral antihistamines: Second generation oral antihistamines such as cetirizine and loratadine should be used although it should be noted that these are not licensed for use in children under two years of age. Cetirizine should not be given in severe renal impairment, and should be used with caution in people with epilepsy. Loratadine should be used with caution in people with severe hepatic impairment with the dose frequency reduced to alternate days.

Possible adverse effects that can occur include blurred vision, dry mouth, headache, diarrhoea, psychomotor impairment and urinary retention. Less sedation and psychomotor impairment occurs compared to first-generation antihistamines as they penetrate the blood-brain barrier to a lesser extent. Although marketed as non-sedating medicines, a small proportion of people will experience sedation, which may have an impact on driving, while drinking alcohol with these medicines may enhance the sedative effect.

Cetirizine and loratadine should be used with caution in women who are pregnant. Both can be used with caution in women who are breastfeeding as they are excreted in breast milk. High doses may inhibit lactation or cause drowsiness.

Intranasal cromones: Intranasal sodium cromoglicate is licensed for use in children and can be used up to four times a day in each nostril. There are no contraindications or listed drug interactions. It is not known to be harmful during pregnancy and is unlikely to be present in breast milk, so can be taken as normal during breastfeeding.

Intranasal decongestants: Intranasal decongestants (e.g. ephedrine and xylometazoline) are licensed for the management of nasal congestion in adults and children. Age restrictions vary, with ephedrine hydrochloride 0.5% nasal drops for use in individuals 12 years and over compared to xylometazoline hydrochloride nasal drops/spray for use in adults and children over six years of age.

Duration of use is limited to seven days for children aged 12 years and over (maximum of five days for xylometazoline in children aged 6-11 years). Long-term use is associated with rebound nasal congestion on withdrawal and tolerance occurs, which reduces the effect of the drug.

Intranasal ephedrine and xylometazoline must be used with caution in people with cardiovascular disease, diabetes, hypertension and hyperthyroidism. With xylometazoline hydrochloride, caution is also needed in those with angle-closure glaucoma and prostatic hyperplasia or enlargement due to the risk of acute urinary retention in men.

There are several possible drug interactions with intranasal ephedrine hydrochloride. Use of both intranasal ephedrine and xylometazoline is not advised during pregnancy. Ephedrine is present in breast milk, and irritability and sleep disturbance have been reported, while intranasal xylometazoline should be used with caution if breastfeeding.

Intranasal anticholinergics: Intranasal ipratropium bromide is licensed for the management of rhinorrhoea associated with allergic rhinitis in adults and children over 12 years of age. It is used two to three times a day in both nostrils with extra care needed to avoid spraying in the eyes. As well as being painful, the spray can dilate the pupils and cause ocular complications. Where this occurs it should be washed out with water for several minutes and medical advice sought where appropriate.

Intranasal ipratropium bromide must be used with caution in people with cystic fibrosis, bladder outflow obstruction and benign prostatic hyperplasia or enlargement (in men) and those at risk of angle-closure glaucoma. Nose bleeds, nasal dryness/ irritation, headache and nausea are common with ipratropium bromide.

Several possible drug interactions are likely including enhanced antimuscarinic effects when combined with drugs such as amitriptyline, baclofen, prochlorperazine, tiotropium and tolterodine. Ipratropium bromide should only be used in pregnancy and breastfeeding if the potential benefit outweighs the risk. Oral leukotriene receptor antagonists

Oral montelukast (Singulair) can be prescribed for adults and children 15 years or over. It is licensed for the symptomatic relief of seasonal allergic rhinitis in people with asthma and taken in the evening. A feeling of thirst is a common side-effect with oral montelukast. Other adverse effects include abdominal pain, headache, agitation, drowsiness, dry mouth, muscle cramps, restlessness and sleep disturbances. Oral montelukast should be avoided in pregnancy and breastfeeding unless essential.

When to refer

Referral may be required in some cases where a prescribed medicine may be more appropriate or where the individual has unresolved severe persistent symptoms and specialist advice is needed.