Allergic rhinitis/rhinoconjunctivitis and non-allergic rhinitis

This can be divided into:

• Perennial rhinitis (also known as persistent rhinitis).

• Seasonal allergic rhinitis

This is most commonly due to grass pollen allergy (hayfever) which occurs from June-August and tree pollen allergy which can run from the end of February to April. A smaller group has an isolated allergy to moulds which sporulate in the autumn.

In patients where there is allergic rhinitis the following can be implemented in primary care:

• High dose non-sedating antihistamines e.g. Fexofenadine 360mg BD, or Loratadine 20mg BD (these are off-licence doses which are known to be safe as per BSACI guidelines for chronic spontaneous urticaria). In pregnancy or lactating women only licenced doses should be used.

• Nasal spray – Steroid nasal spray such as Fluticasone or Beclomethasone. Correct administration technique is important, please advise the patient, an information leaflet can be found here (second page) Howtouseanasalspray.pdf

Where steroid nasal spray fail, Azelastine/Fluticasone preparation (Dymista) may be considered

• Eye drops- either Sodium cromoglycate or Olopatadine.

• If there is concomitant asthma, control should be optimised as immunotherapy/desensitisation is contraindicated in cases where the patient has poorly controlled asthma.

• In individuals who have asthma like symptoms during the pollen season a steroid inhaler may be considered.

• Allergic rhinitis which is persistent is nearly always in the United Kingdom secondary to house dust mite allergy. Management strategies for persistent rhinitis are similar to those outlined for seasonal rhinitis.

• A subgroup of patients may have perennial rhinitis due to animal dander (cat, dog) sensitisation and a pet at home. Such patients will often experience relief when away from the animal. Individuals who are allergic to their pets should be encouraged to rehome them in addition to the measures above. Immunotherapy/desensitisation to animal dander is often poorly tolerated and reserved for individuals who have occupational risks e.g. Veterinary surgeons and nurses, animal handlers, farmers.

Non- allergic rhinitis presents in a similar nature to perennial rhinitis; however, the symptoms do not co-exist with allergy conjunctivitis type symptoms. It typically presents later in life and is less responsive to antihistamines and tends to be watery in nature.

It may be made worse by temperature changes, sulphite rich foods and often co-exists with Aspirin Exacerbated respiratory disease.

A negative specific IgE RAST to an aeroallergen mix in the context of a normal or high IgE and supportive clinical features are enough to make a diagnosis of non-allergic rhinitis. Patients who have been seen by community ENT and have negative skin prick tests are likely to have non allergic rhinitis.

The following should be implemented where there is a suspicion of allergic rhinitis:

• Up to four times the licenced dose of a non-sedating antihistamine e.g. Fexofenadine 360mg BD

• Ipratropium Bromide nasal spray, 2 sprays each nostril 2-3 times a day

• A trial of Montelukast 10mg once at night