Download MANAGEMENT OF SEASONAL ALLERGIC RHINITIS (HAY FEVER)

MANAGEMENT OF SEASONAL ALLERGIC RHINITIS (HAY FEVER)
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NON-SEDATING ANTIHISTAMINES
 These antihistamines cause less sedation then older antihistamines because
they penetrate the blood-brain barrier only to a slight extent1.
 For mild and intermittent symptoms, cetirizine tablets (95p/28tabs) or
loratadine tablets (£1.06/28tabs) are first line choices used regularly or as
required.
 Desloratadine and levocetirizine are not recommended because there is little
evidence that they confer any additional benefit over the more established nonsedating antihistamines,2 and they are more costly as shown in the graph below.
 Fexofenadine 180mg is only licensed for chronic idiopathic urticaria.
 Mizolastine and rupatidine can both cause QT interval prolongation.
 Cetirizine capsules cost £11.64 for 28 days and therefore should not be used
first line.
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 Azelastine (Rhinolast ) is the only antihistamine nasal spray alone, with
therapeutic effects superior to oral antihistamines for rhinitis symptoms3 (£7.84
for 28 days treatment).
NASAL PREPARATIONS
 Intranasal corticosteroids (INCS) are preferred as treatment for
persistent and/or moderate to severe symptoms.1st choice is twice daily
Beconase® (£2.19/200dose) or beclometasone (£2.27/200 dose).
Note that Beconase 180 dose container is more expensive and should
not be used. 2nd line is once daily budesonide 64mcg
(£3.85/120dose)
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 If fluticasone is required, prescribe as Avamys (£6.44/120dose) or
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Nasofan (£8.04/150 dose) which are more cost effective then
prescribing generically
 Remind patients about the importance of following the correct nasal
inhalation technique (e.g. tilting head forward/ not sniffing too hard etc.)
as poor technique may be related to treatment failure
 Reduce the dose of nasal spray to a maintenance dose once
symptoms are controlled.
Note: products with a star are available to purchase over the counter
EYE DROPS
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 1 choice is sodium cromoglicate 13.5ml (£1.61/13.5ml). Consider smaller
pack size i.e. 10ml if patient is purchasing over the counter.
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 Antihistamine eye drops Otrivine Antistin (£2.35/10ml) are suitable for rapid,
short term relief of infrequent ocular symptoms. Avoid in angle-closure glaucoma.
* costs based on lowest maintenance dose
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Azelastine hydrochloride with fluticasone (Dymista)
Dymista® nasal spray contains 137micrograms of azelastine hydrochloride
and 50micrograms of fluticasone propionate. It is more expensive then using azelastine and fluticasone sprays individually, and the PCN do not support routine prescribing of Dymista® and consider this a black drug.
MANAGEMENT OF SEASONAL ALLERGIC RHINITIS (HAY FEVER)
SELF CARE
Encourage self-care if symptoms are mild – many antihistamines, nasal
sprays and eye drops are available over the counter for less than the current
NHS prescription charge.
All patients should take practical measures to avoid excessive exposure to pollen
and other allergens by:
 Keeping windows and doors shut
 Avoiding cut grass, large grassy places, and camping
 Showering and washing hair after being outdoors, especially after going to the
countryside
 Wearing wrap-around sunglasses when outside
 Bringing in washing, and closing windows before the evening
Useful Patient information leaflets are available at
www.patient.co.uk/health/hay-fever.htm
GUIDANCE SUMMARY (ADULTS)
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Oral antihistamines - cetirizine or loratadine
INCS - Beconase® Aqueous 200 dose and Budesonide 2nd line
Eye drops - sodium cromoglicate 13.5ml. Otrivine Antistin®10ml,
Nedocromil sodium 5ml.
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SPECIAL PATIENT GROUPS
Prescribing for children
 Treatment similar to that in adults. Liquid cetirizine 1mg/ml(£1.78/200ml)
from 1 year of age and chlorphenamine 2mg/5ml (£2.49/150ml) from
one month old are available- see BNF for children (3.4.1)
 If INCS is required for short term use, consider Beconase® Aqueous (618years). For long term use, prescribe once daily preparations such as
budesonide / fluticasone furoate / mometasone or triamcinolone.
Caution - height of children on prolonged INCS treatment should be
monitored – see BNF for children (12.2.1)
Pregnancy and breastfeeding
 INCS is the treatment of choice. If antihistamine is required, loratadine
should be used. Any medication prescribed should be at the lowest
effective dose and for the shortest time necessary.
EFFICACY OF MEDICATION TYPE BY SYMPTOM
Taken from NHS Barnsley APC guideline May 2012
Key:
++++ most effective
- no effect
OTHER TREATMENTS
 Intranasal decongestants such as ephedrine and xylometazoline nasal
drops can be used to rapidly relieve nasal blockage. Short term use (710days) is advised in order to avoid rebound effect. These nasal sprays
can be purchased without prescription. Normal saline drops can be used
in infants.
Kenalog® injection
 Depot steroids should not be prescribed for hay fever. Evidence of safety
is lacking, and there is a significant risk of prolonged side-effects (e.g.
osteoporosis) which cannot be mitigated by withdrawal of the drug.
Grazax®
 Treatment should only be initiated by an allergy specialist 4 months prior to
the start of hay fever season and be continued daily for 3 years. This is
expensive and only to be considered when other anti-allergy treatments
have failed.
REFERENCES AND WEBLINKS
1. BNF66, September 2013
2. Clinical knowledge summaries - allergic rhinitis www.cks.nhs.uk/allergic_rhinitis
3. BSACI guidelines for the management of allergic and non-allergic rhinitis http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2222.2007.02888.x/pdf
4. All prices taken from Drug Tariff February 2014 and MIMS online February 2014