Allergic rhinitis in general practice

2. Why is allergic rhinitis
important?
NB - Most of the information in this presentation is from the ASCIA website -
www.allergy.org.au
ASCIA allergic rhinitis e-training - 1.5 hours

3. Learning Objectives
● Recognise clinical features of allergic rhinitis & possible co-existent conditions
● Uses and limitations of allergy testing
● Non-pharmacological therapy options
● Pharmacotherapy
● Immunotherapy
● Role of Gps in management of allergic rhinitis
● When to consider referral to a specialist

4. Overview
● Most common allergic disorder in Australia and NZ
● Often underdiagnosed and undertreated
● Most common between 35-44yo (Uncommon <2yo)
● Can have significant impact on
○ Sleep
○ Alertness and Concentration
○ Learning
○ Daily Function
○ Childhood behaviour and development

5. Allergic rhinitis Causes
IgE mediated response to one or all of the following aeroallergens-
● HDM
● Pollen (see www.pollenforecast.com.au)
● Animal Dander
● Mould spores
Not caused by food

6. Clinical Features
● Acute symptoms
○ Sneezing, itchy nose, clear rhinorrhea
○ Itchy throat
● Other Features
○ mouth breathing
○ Snoring
○ Dry lips
○ Wake up tired
○ Allergic pleats
● Chronic symptoms
○ Nasal blockage
○ Loss of smell

7. Clinical assessment
Important questions in clinical history to consider
● Timing of symptoms - perennial vs seasonal
● Impact of symptoms - eg affecting day to day function
● Frequency and Duration of symptoms
● Triggers identifiable
● Coexistent conditions
● Medications - tried and effectiveness

8. Co-existent conditions
Asthma
● United Airway Disease
● Effective treatment of allergic rhinitis improves asthma management
● 80% asthmatics have AR
● 40% of AR pts have Asthma
Other conditions
● Eustachian tube dysfunction
● Allergic conjunctivitis
● Nasal polyps
● Eczema
● Rhinosinusitis

9. Uses and limitations of allergy testing
● Diagnosis - clinical
● Investigations - usually not needed (FBC and sIgE are of little use)
● Treatment - can be started without allergy testing.
● RAST - high rate of false positives
● SPT - is more sensitive and specific than RAST
● Positive tests do not automatically prove the allergen is causing the
symptoms
● Food specific IgE testing should not be done

10. Treatment

11. Allergen Avoidance - House Dust Mite
● Mattress & Pillow Covers - Dust mite impermeable (eg Allergend)
● Pillows - Frequently wash and replace
● Hot wash linens (or cold wash with tea tree/eucalyptus wash eg Bossitos)
● Hot tumble drying for 10 min
● Freeze fluffy toys for 24 hours or wash in eucalyptus wash
● Vacuum carpets weekly using HEPA filter
● Damp dust

12. Allergen Avoidance - Pollen
● Stay indoors -
○ Thunderstorms
○ Windy Days
○ Lawns are being cut (don’t leave clippings on ground)
● Wear sunglasses to reduce the amount of pollen that gets into eyes
● Dry bedding and clothing inside or in tumble dryer

13. Allergen Avoidance
● Can be difficult to achieve
● Consider family’s financial status
Nasal saline irrigation
Food elimination/avoidance is not required

14. Intranasal Steroids
● Persistent symptoms and/or impairment of day-day functioning
● Instructed on the correct and consistent use of intranasal sprays
● Superior to antihistamines
● Take a few days to start working
● When symptoms improve, pharmacotherapy can be reduced (at least 4
weeks). Restart if symptoms recur
● Side effects - headache, nose bleeds, thrush (bleeding uncommon when
correctly administered). Minimal potential for systemic absorption

15. Correct administration of INCS
1. Use saline spray first and blow nose
2. Prime INCS spray (if new device or period of non-use)
3. Shake the bottle before each use
4. Blow nose before spraying
5. Tilt head slightly forward and insert nozzle into nostril.
6. Use R hand for L nostril and vice versa
7. Aim nozzle away from midline (not upwards)
8. Avoid sniffing hard during or after spraying

16. Other Pharmacotherapy options
● Oral Antihistamines (non sedating) can be used for symptom control
● Intranasal antihistamines - only in kids >5yo but usually not tolerated by kids
● Dymista - combined intranasal antihistamine and corticosteroids - >12yo
(need script)

17. If poor response to treatment
Review -
● Compliance to medication
● Administration technique
● Allergen avoidance
● Differential diagnoses - if ongoing nasal obstruction consider adenoidal
obstruction

18. Aeroallergen Immunotherapy
● Closest thing we have to a cure (ie treats the cause of AR)
● Reduces the frequency and severity of symptoms of allergic rhinitis (on
average 50% reduction in sx and/or medication need).
● Recommended in AR when
○ Symptoms are severe
○ Cause is difficult to avoid
○ Medications don’t help or cause side effects
○ People prefer to avoid medications
● Can also reduce asthma exacerbation

19. Aeroallergen immunotherapy
● Commercial available aeroallergens - HDM, pollens, animal dander, mould
● 3-5yrs of regular administration of increasing doses of allergen extracts
● SCIT - initially weekly injections for up to 6mo then monthly thereafter;
○ 3-5 years, high risk of severe allergic reaction
● SLIT - daily; but costs more, 3 years. Risk of reactions very low
● There hasn’t been a big study comparing SCIT and SLIT directly. The efficacy
difference between SCIT and SLIT is debated.
Turbinate reduction can help with symptom management whilst waiting for
immunotherapy to occur

20. Role of GPs in management of allergic rhinitis
● Detection and diagnosis of allergic rhinitis (important)
● Diagnosis and management of co-existant conditions eg asthma
● Initiation of pharmacotherapy if required
● Education of patient on prevention and treatment
● Encourage compliance
● Referral to specialist when indicated
● Ascia allergic rhinitis Action plan

21. When to consider referral to a specialist
● Severe or inadequate controlled allergic rhinitis persists (do 4/52 INS first)
● ENT if -
○ Unilateral symptoms or nasal polyps
○ Significant impact on quality of life
○ Chronic eustachian tube dysfunction
○ Suspected adenoidal hypertrophy
● Allergist/Immunologist if -
○ Consideration of immunotherapy
○ Further allergy testing is required to facilitate allergen avoidance
○ Other atopic comorbidities require management
Turbinate
reduction offers
symptom relief
only

22. If you forget all else, remember this -
ASCIA website has information for
● Doctors
● Patients/parents