The classification of rhinitis can be summarised as:
Allergic rhinitis May be seasonal or perennial. It can be classified as either intermittent (lasting for <4 days of the week or <4 weeks) or persistent (lasting >4 days of the week or >4 weeks).
The severity of symptoms is classified as either mild (normal function including sleep and only slightly troublesome symptoms) or moderate/severe (troublesome symptoms with impairment of activities).9 Its prevalence has increased worldwide, affecting 20% of the adult population and up to 40% in children; 60% have a family history. It varies from 5–20% with a peak prevalence in children and young adults up to 20%.11 The symptoms are caused by release of powerful chemical mediators such as histamine, serotonin, prostaglandins and leukotrienes from sensitised mast cells.11
Seasonal allergic rhinoconjunctivitis (hay fever)
This is the most common type of allergic rhinitis and is due to a specific allergic reaction of the nasal mucosa, principally to pollens. The allergens responsible for perennial allergic rhinitis include inhaled dust, dust mite, animal dander and fungal spores.
Most cases of hay fever begin in childhood with one-half of eventual cases having the problem by the age of 15 and 90% by the age of 30.12 Approximately 20% suffer from asthma.
While patients with hay fever tend to have widespread itching (nose, throat and eyes), those with perennial rhinitis rarely have eye or throat symptoms but mainly sneezing and watery rhinorrhoea. Nasal polyps are associated with this disorder (refer to CHAPTER 59).
Management consists of four main areas:
appropriate explanation and reassurance
Intranasal corticosteroids which reduce inflammation and nasal secretions are first-line treatment for moderate to severe cases.14
Keep healthy, eat a well-balanced diet, avoid ‘junk food’ and live sensibly with balanced exercise, rest and recreation. If your eyes give you problems, try not to rub them, avoid contact lenses and wear sunglasses.
Avoid using decongestant nose drops and sprays: although they soothe at first, a worse effect occurs on the rebound.
Avoidance therapy: avoid the allergen, if you know what it is (consider pets, feather pillows and eiderdowns).
Sources of the house dust mite are bedding, upholstered furniture, fluffy toys and carpets. Seek advice about significantly reducing the dust in your bedroom or home, especially if you have perennial rhinitis.
Pets, especially cats, should be kept outside.
Avoid chemical irritants such as aspirin, smoke, cosmetics, paints and sprays.
This is difficult during the spring pollen season, particularly where patients are living in high-pollen (e.g. country farming) areas, or spending considerable time outdoors in the course of work or sporting and recreational activities.
Therapy can be chosen from:
decongestants (oral or topical)
intranasal (not so effective for non-eosinophilic vasomotor rhinitis)
oral (very effective if other methods fail)
ophthalmic drops for allergic conjunctivitis
Consider hyposensitisation/immunotherapy when specific allergens are known (very important) and conventional response is inadequate. Immunotherapy to grass pollen is generally very effective and should be considered in moderate to severe springtime hay fever. Immunotherapy by injection or oral administration can be labour-intensive, often taking years.
Oral antihistamines are the first line of treatment for seasonal hay fever and are generally effective where symptoms are intermittent, or when used prophylactically before periods of high pollen exposure. The newer ‘non-sedating’ antihistamines that do not cross the blood–brain barrier are used in preference to the first-generation drugs, although some degree of sedation may occur even with these. A list of non-sedating antihistamines is presented in TABLE 80.3. It is claimed by some that the newer topical preparations, levocabastine and azelastine, as intranasal sprays, are rapidly effective for an exacerbation of symptoms. If sedation is desirable (e.g. overnight), a sedating antihistamine can be used.
Table 80.3Less sedating antihistamines (oral regimens) |Favorite Table|Download (.pdf) Table 80.3 Less sedating antihistamines (oral regimens)
|Generic name ||Onset ||Adult dosage |
|Cetirizine ||Rapid ||10 mg daily |
|Desloratadine ||Very rapid ||5 mg daily |
|Fexofenadine ||Rapid ||60 mg bd |
|Loratadine ||Very rapid ||10 mg daily |
Oral sympathomimetics, either used alone or in combination with antihistamines (where they may help reduce drowsiness), may be of some value, particularly where nasal discharge and stuffiness are major symptoms. Side effects include nervousness and insomnia. They should be used cautiously in patients with hypertension, heart disease, hyperthyroidism, glaucoma and prostatic hypertrophy.
Intranasal decongestants should be used for limited periods only (i.e. less than a week) or intermittently (3–4 doses per week) because of the potential problems with rebound congestion and rhinitis medicamentosa. They are often of particular value during the first week of treatment with intranasal corticosteroids (where the onset of action is delayed several days), improving nasal patency and allowing more complete insufflation of the corticosteroids. Adverse reactions similar to those of oral decongestants may occur.
Intranasal sodium cromoglycate acts by preventing mast cell degranulation and is effective without serious side effects. The capsule variety must be used (the spray form requires 1–2 hourly dosage to be effective); it is useful in perennial allergic rhinitis but is not as effective as intranasal corticosteroids for springtime hay fever.
Intranasal corticosteroid sprays are the most effective agents for treating seasonal allergic rhinitis. Side effects are minimal and adrenal suppression is not a problem with normal usage. Patients should be informed that these medications will not give immediate relief (often taking 10–14 days to have peak effect) and must be used continuously throughout the hay fever season for at least 6–8 weeks. Local side effects include dryness and mild epistaxis.
Intranasal antihistamines group—includes azelastine and levocabastine—are effective at relieving itching and sneezing.
TABLE 80.4 lists intranasal preparations for rhinitis.
Table 80.4Intranasal preparations for rhinitis |Favorite Table|Download (.pdf) Table 80.4 Intranasal preparations for rhinitis
| ||Brand name ||Dosage ||Comments |
|Sodium cromoglycate ||Rynacrom powder (capsules) ||Insufflate 1 capsule, qid 2% ||Compliance a problem |
|Rynacrom nasal spray ||Spray 4–6 times daily 4% || |
| ||Spray 2–4 times daily || |
|Beclomethasone dipropionate 50 mcg/spray ||Beconase Hayfever ||100 mcg spray each nostril bd or tds || |
|Budesonide 64 mcg/spray ||Budamax nasal ||1–2 sprays each nostril daily || |
|Rhinocort nasal || || |
|Ciclesonide 50 mcg/spray ||Alvesco, Omnaris ||2 sprays each nostril daily || |
|Fluticasone furoate 27.5 mcg/spray ||Avamys ||2 sprays each nostril daily, reducing to 1 spray || |
|Fluticasone propionate 50 mcg/spray ||Beconase Allergy 24 hour aqueous ||2 sprays each nostril daily reducing to 1 spray || |
|Mometasone furoate 50 mcg/spray ||Nasonex ||2 sprays per nostril daily || |
|Triamcinolone 55 mcg/spray ||Telnase ||2 sprays each nostril daily reducing to 1 spray || |
|Ipratropium bromide ||Atrovent ||1–2 sprays per nostril tds prn ||Useful for vasomotor rhinitis and profuse rhinorrhoea |
|Care needed with elderly |
|Azelastine ||Azep ||1 spray each nostril bd ||Antihistamine |
|Levocabastine 0.05% ||Livostin ||2 sprays each nostril bd ||Antihistamine, max. 8 weeks |
|Various sympathomimetics (e.g. phenylephrine) || ||2, 3 or 4 times daily (max. 7 days) ||Short-term use only |
|Care with elderly, prostatic hypertrophy |
Sodium cromoglycate eyedrops are usually very effective for springtime conjunctivitis. They can be used as necessary (no dosage limit) and are most helpful when used prophylactically before periods of high pollen exposure. Decongestant eyedrops may also be helpful (care with narrow angle glaucoma), while corticosteroid eyedrops are reserved for resistant allergic conjunctivitis and should be used with care to exclude infection and glaucoma. Antihistamine eyedrops antazoline and levocabastine are yet another option.
These can be very effective where other treatments or methods have failed. A 6–10 day short course can be used. An example of a 6-day ‘rescue course’ is prednisolone 25, 25, 20, 15, 10, 5 mg daily doses.
Ipratropium bromide (Atrovent)13
The nasal preparation of this topical anti-cholinergic is often very effective when rhinorrhoea is the major problem.
Leukotriene receptor antagonist
Regarded as equivalent to oral antihistamines, they have a place in the management of children with concurrent asthma and hay fever (e.g. montelukast).
Inferior turbinate reduction aims to reduce the size of turbinates and so reduce nasal obstruction when congested.
Guidelines from elite task force15
For initial treatment of seasonal allergic rhinitis in people aged 12 or older, routinely prescribe monotherapy with an intranasal corticosteroid rather than an intranasal corticosteroid in combination with an oral antihistamine.
For initial treatment of seasonal allergic rhinitis in those aged 15 or more, recommend an intranasal corticosteroid over a leukotriene receptor antagonist.
For treatment of moderate to severe seasonal allergic rhinitis in people 12 or older, you may recommend the combination of an intranasal corticosteroid and an intranasal antihistamine initially.
TABLE 80.5 summarises recommended steps in management.
Table 80.5Summary of recommended treatment steps for allergic rhinitis9 |Favorite Table|Download (.pdf) Table 80.5 Summary of recommended treatment steps for allergic rhinitis9
|Patient education |
|Allergen avoidance (if possible) |
|Mild cases: |
|Moderate to severe (persistent): |
intranasal corticosteroids (as preventer—the most effective)
sodium cromoglycate (Opticrom) eyedrops
oral corticosteroids (if topicals ineffective)
immunotherapy if applicable