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FEBRUARY 2012 A ALLERGIC RHINITIS llergic rhinitis or ‘hayfever’ is one of the most common chronic respiratory conditions in Australia. Predominant symptoms are rhinorrhoea (‘runny nose’), nasal obstruction, nasal itching and sneezing. It can cause significant irritation and interference in daily activities, considerably reducing quality of life. Intermittent allergic rhinitis is defined as symptoms that are present for less than 4 days per week, or less than 4 weeks at a time. Persistent allergic rhinitis is defined by symptoms that are present for more than 4 days per week, and for more than 4 weeks at a time. Other conditions that commonly occur with allergic rhinitis include asthma, chronic sinusitis, otitis media (middle ear The severity of allergic rhinitis is classified as either mild infection) and decreased quality of sleep. or moderate/severe. With mild allergic rhinitis, there is no impairment of sleep, daily activities, leisure or sport; and the symptoms are not considered troublesome by the patient. With Prevalence Allergic rhinitis affects around 15% of the Australian moderate/severe allergic rhinitis, these impairments are present population or around 3 million people. It is reported slightly and considered troublesome. more commonly by females than males. The condition is most commonly reported by those aged 25-44 years, and less Management common by young people less than 14 years of age and people Although there is no cure for allergic rhinitis, effective treatment older than 75 years, but the incidence is still around 10% in the is available. older age group. Optimal symptom control can be achieved through allergen In a recent Australian Institute of Health and Welfare (AIHW) avoidance, pharmacotherapy, non-medicated treatments and report the ACT and Western Australia had the highest rates of immunotherapy. allergic rhinitis in Australia, with Queensland and New South Wales the lowest. Drug Treatment First line therapy for the management of allergic rhinitis is Causes intranasal corticosteroids and oral antihistamines. Genetic and environmental factors contribute to the onset and development of allergic rhinitis. For persistent allergic rhinitis and for moderate/severe intermittent allergic rhinitis, guidelines recommend use of Common triggers of allergic rhinitis include dust mites, animal intranasal corticosteroids as the first-line therapy. If patients fur, pollens, fungal spores, air pollutants and occupational are not adequately controlled by intranasal corticosteroids, the sources. Evidence of the effectiveness of allergen avoidance additional use of oral antihistamines is recommended. measures, particularly house dust mite, is limited. For mild intermittent allergic rhinitis, the use of antihistamines is recommended as first-line therapy. For those whose symptoms Signs and Symptoms The symptoms of allergic rhinitis are caused by an allergic not adequately controlled by antihistamines, the additional use reaction in the inner linings of the nose resulting in inflammation. of intranasal corticosteroids is recommended. Common signs and symptoms include: ■■ itch ■■ mucus discharge ■■ sneezing ■■ post-nasal drip ■■ cough ■■ facial fullness and pain ■■ obstruction ■■ snoring ■■ sleep interference Classification Allergic rhinitis can be classified into two categories: ■■ Intermittent ■■ Persistent © Manrex Pty Ltd (ABN: 63 074 388 088) t/as Webstercare - 2012 Intranasal corticosteroids Examples of intranasal corticosteroids include: ■■ Beclomethasone (Beconase 12 hour) ■■ Triamcinolone (Telnase) ■■ Fluticasone (Avamys, Flixonase) ■■ Budesonide (Rhinocort Hayfever, Rhinocort, Budamax) ■■ Mometasone (Nasonex) Benefit appears after 3 to 8 hours but maximum effect may require up to 2 weeks. Intranasal corticosteroids should be used regularly, but still have benefit if used on intermittent basis, for example in pollen season. Intranasal corticosteroids have been shown to improve quality Allergic Rhinitis, continued of life and reduce sleep problems associated with nasal congestion. They are more effective than oral or intranasal antihistamines or topical sodium cromoglycate. Intranasal corticosteroids have good long-term safety data, but the lowest dose that will control symptoms should be used. The total steroid dose should be considered if used with intercurrent asthma. Systemic side effects typical of steroids such as osteoporosis, diabetes and hypertension have not been reported. Antihistamines Oral and topical antihistamines are effective in allergic rhinoconjunctivitis and histamine related symptoms such as itching, rhinorrhoea and sneezing. They are less effective for nasal blockage. Oral antihistamines that are less sedating are preferred: ■■ Cetirizine (Zyrtec) ■■ Desloratadine (Claramax, Aerius) ■■ Fexofenadine (Telfast, Fexotabs, Xergic) ■■ Levocetirizine (Xyzal) ■■ Loratadine (Claratyne, Allereze) There may be a marked variation in response to different antihistamines, but there is no evidence that any one agent is superior. If unresponsive it is worth trying a different antihistamine. Older antihistamines (e.g. Polaramine, Phenergan, Vallergan) should be avoided in older people as they cause sedation, somnolence, fatigue and impaired psychomotor performance, as well as anticholinergic effects (dry mouth, constipation, blurred vision, urinary retention). Nasal antihistamines including azelastine (Azep) and levocabastine (Livostin) are as effective as oral antihistamines, but not as effective as intranasal corticosteroids. Other nasal sprays Cromoglycate nasal spray (Rynacrom) is an effective mast cell stabiliser. It may cause irritation of nasal mucosa and infrequently nosebleeds. Ipratropium (Atrovent Nasal, Atrovent Nasal Forte) is an anticholinergic nasal spray which dries nasal secretions and may reduce rhinorrhoea, but has no effect on nasal blockage or on other symptoms of allergic rhinitis. Nasal decongestants Nasal decongestants such as oxymetazoline (Drixine), tramazoline (Spray-Tish) or xylometazoline (Otrivin) may be used in cases of severe nasal blockage, but only for up to 5 days, as rebound congestion may occur. Eye drops Anti-allergy eye drops are effective additional therapy when ocular symptoms persist despite treatment with intranasal steroids or oral antihistamines. Antihistamine-mast cell stabilisers such as ketotifen (Zaditen) and olopatadine (Patanol) are effective for rhinoconjunctivitis and require twice daily instillation. Other antihistamine eye drops such as azelastine © Manrex Pty Ltd (ABN: 63 074 388 088) t/as Webstercare - 2012 (Eyezep) and levocabastine (Livostin) often need to be used 3 or 4 times daily. Leukotriene antagonists Leukotriene receptor antagonists (montelukast, zafirlukast) are oral preparations used also for asthma and allergic rhinitis, but are less effective than intranasal corticosteroids. Immunotherapy Immunotherapy should be considered for patients with moderate or severe persistent allergic rhinitis that is not responsive to usual treatments. Oral (sublingual) and injectable (subcutaneous) forms of immunotherapy are available. Adherence A common reason for treatment failure is non-adherence due to local side effects such as dryness, irritation and epistaxis. Nasal saline spray can be used before intranasal steroids to clear mucus, improving contact with the steroid and potentially reducing the dose required to be effective. Administration Correct administration technique is vital to gain the most benefit from intranasal sprays. First the bottle should be shaken gently. The resident should tilt the head forward slightly and close one nostril with a finger. Use the right hand for the left nostril and put the nozzle just inside the nose and aim to the side away from the central ridge of the nose. Breathe in gently. Switch nasal inhaler to other hand and repeat for the other side. Breathe out through the mouth. Finish by wiping the nozzle and replacing the cap. Summary Allergic rhinitis or hayfever is a chronic condition experienced by about 1 in 10 older people. It is the most common chronic respiratory condition in Australia. Allergic rhinitis may significantly affect quality of life, worsen asthma control and cause sleep and cognitive disturbances. The goal of allergic rhinitis management is to achieve optimal symptom control. References Australian Institute of Health and Welfare 2011. Allergic rhinitis (‘hay fever’) in Australia. Cat. no. ACM 23. Canberra: AIHW. ARIA in the pharmacy: management of allergic rhinitis symptoms in the pharmacy. Allergy 2004:59:373–387.