One airway disease
AR is an independent risk factor for developing asthma, and increases the risk of a patient’s asthma being poorly controlled
Treating AR can improve patient’s asthma symptoms and reduce the odds of asthma-related emergency department visits and hospitalisations
Respiratory symptoms thought to be caused by asthma (coughing, wheezing, and breathlessness) may sometimes be solely caused by AR.
Top tips for patients
Allergens are usually tree pollen (spring), grass pollen (end of spring/beginning of summer), or weeds (early spring to late autumn)
Allergen avoidance strategies can help reduce symptoms, such as minimising outdoor activity, wearing wraparound sunglasses, shutting windows in cars and buildings, using nasal filters, avoiding drying clothes outside when the pollen count is high, and showering and washing hair after pollen exposure[3,4]
Patients should start using treatment two weeks before they normally experience symptoms and stop at the end of the season.
The Met Office pollen forecast (for the UK) can help with timings of when there is high to very high pollen count (see useful resources)
Pollen food syndrome affects some people with hay fever. Symptoms of itching and/or swelling of the lips, tongue, and mouth and/or throat may be experienced on eating some fruits, vegetables, or nuts, such as apples, because of the cross-reactivity between these foods and pollens, such as birch tree pollen.[3,8]
Explain that treatment will be trialled for two to four weeks to enable diagnosis and assess its effectiveness, but a change in medication or referral may be required on review
Advise patients when to expect improvement in symptoms:
Explain that treatment is only effective if taken every day as directed
Teach patients how to use nasal sprays correctly (see useful resources) and check their technique at each review
Warn patients about possible side effects – some patients may experience a bitter taste with azelastine, and epistaxis is a possibility with intranasal steroids.
Considerations for healthcare professionals
Questions about AR symptoms should be phrased according to the patient’s level of understanding and linguistic ability
Check which medicines patients have tried previously and whether any were effective
Remember to check patients with AR for asthma symptoms.
In exceptional circumstances (for example, the patient’s wedding day), it may be appropriate to use a short course of oral prednisoloneC to rapidly alleviate symptoms
Injectable steroids (for example, triamcinolone acetonide) should not be used for AR because of a poor risk–benefit profile.
A visual analogue scale is a simple scoring system to measure AR symptoms (0 to 10) and show improvement, which can help improve patient concordance with treatment and achieve optimum control
Where possible, patients can use the MASK–air app to record daily symptoms, enabling a simple treatment decision after two to four weeks trial of treatment based on changes to the patient’s score
The two to four week review can be carried out by phone, email, or video consultation
Mometasone is licensed for use in children ≥3 years
Combination intranasal steroid and intranasal antihistamine treatment is not licensed in children under 12 years.
C: Not currently recommended due to COVID-19.
How to use nasal spray: www.asthma.org.uk/advice/inhaler-videos/nasal-spray/
BSACI. How to apply a nasal spray: www.bsaci.org/wp-content/uploads/2019/12/Howtouseanasalspray.pdf
How to do nasal douching: www.youtube.com/watch?v=GW2PiOFhFtY
BSACI. Nasal douching: www.bsaci.org/wp-content/uploads/2019/12/Howtoperformnasaldouching.pdf
Allergy UK factsheet on hay fever: www.allergyuk.org/information-and-advice/conditions-and-symptoms/11-hay-fever-allergic-rhinitis
MASK-air app: www.mask-air.com/
Met Office pollen count: www.metoffice.gov.uk/weather/warnings-and-advice/seasonal-advice/pollen-forecast
Date of preparation: July 2020
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Medscape © 2020 WebMD, LLC
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Identifying and Managing Allergic Rhinitis in the Asthma Population - Medscape - Aug 17, 2020.