ANP and allergy nurse specialist Katherine Knight explains best practice in the management of seasonal allergic rhinitis and advises how to support patients to control their symptoms effectively
Seasonal allergic rhinitis, also referred to as hayfever, is a common allergic condition that affects approximately 20% of the UK population.1 Symptoms are wide ranging and can have a significant adverse effect on an individual’s quality of life. Despite this, it is often under-diagnosed and inadequately managed.1,2
With pollen season upon us, practice nurses are in a unique position to help their patients understand their condition and control their symptoms.
What is seasonal allergic rhinitis and how can it affect people?
Allergic rhinitis (AR) refers to inflammation of the nasal mucosa, triggered by inhaled aeroallergens (airborne particles that can cause allergic illnesses) stimulating a localised IgE mediated allergic response. Seasonal AR is triggered by tree pollen (spring) and grass pollen (summer). Allergy UK has a pollen calendar’ which shows the timing of key pollen allergens throughout the year. Seasonal allergic rhinitis can be classified as intermittent or persistent, and mild or moderate-severe.
Typical symptoms of AR include clear and watery bilateral rhinorrhoea (runny nose from both nostrils), nasal congestion and itch. Eye symptoms include itch, redness, oedema and watery discharge; when both nasal and eye symptoms are present this is termed allergic rhino-conjunctivitis.
The presence of AR is a risk factor for the development of asthma,1,3,4 since the upper and lower airways are connected, and those with pre-existing asthma often experience deterioration in asthma symptoms if AR is not well controlled.
Individuals with uncontrolled seasonal AR may experience poor sleep leading to fatigue and reduced attendance and performance at school or work.2 Children can experience bullying at school due to persistent nasal snorting and discharge.
What can patients do to help manage their symptoms?
Allergen avoidance is difficult for those with seasonal AR since tree and grass pollen is present in the air and dispersed by wind and warm weather. Individuals should be advised to monitor the pollen forecast and take precautions on high pollen count days. These include: avoiding drying clothes outside; wearing a hat and sunglasses outside; showering; washing hair and changing clothes when arriving home and keeping windows closed in the morning when pollen is being released; and in the evening, when the air cools and pollen falls. Applying a layer of balm, such as petroleum jelly, to the nostrils may help to trap pollen. Despite non-pharmacological measures, most individuals with seasonal AR will need medication to gain good control of their symptoms.
Related Article: Mythbuster: ‘It’s just hay fever – you can get all the treatment you need over the counter’
How effective are over-the-counter treatments?
An over-the-counter (OTC) non-sedating long-acting oral antihistamine, such as cetirizine, fexofenadine or loratadine is the first line treatment for mild-moderate seasonal AR and should be taken regularly rather than ‘as required’.1,5
First-generation antihistamines such as chlorphenamine should be avoided due to their sedative effect and short duration of action.1
Antihistamines will only help with histamine driven symptoms such as rhinorrhoea, nasal, eye or skin itch and have a minimal effect on nasal congestion.
Oral decongestants such as pseudoephedrine are NOT recommended for the management of seasonal AR due to poor effectiveness in reducing nasal obstruction and numerous side effects.1
Saline nasal irrigation can also be used to wash pollen from the nose and is well tolerated in both children and adults.6 OTC mast cell stabiliser eye drops such as sodium cromoglycate can help with eye itch and tear supplement drops may also provide symptom relief.1
When might patients need a prescription medication and what is effective?
A stepwise approach to prescribing medication for seasonal AR should be followed as outlined in British Society of Allergy and Clinical Immunology (BSACI) guidance.1 Regular use of intranasal steroids (INS) is the mainstay of treatment for those with persistent nasal congestion and works to reduce nasal inflammation and the symptoms of congestion and mucous production. 1 These should be used alongside oral antihistamine and saline nasal rinsing, taking care to use saline rinsing before and not after the nasal spray.
Due to the high steroid bioavailability of OTC INS, prescription-only lower steroid bio-availability INS are preferred for management of allergic rhinitis; the BSACI has a full list of steroid bioavailability.1
INS do not work immediately and may take up to 2 weeks before they provide any benefit. It is therefore important that patients with seasonal AR start using their nasal spray 2 weeks before symptoms are expected, where possible, based on their known allergens.
The patient should be advised to use daily and employ the correct technique; adherence and nasal spray technique should be checked regularly and the patient provided with written and/or visual instructions.
Anti-leukotriene medications, such as montelukast, work by blocking the inflammatory action of leukotrienes thus reducing nasal congestion. They are not as effective as INS in controlling nasal inflammation and are not used as a stand-alone treatment in the patient with seasonal AR. They may be prescribed alongside oral antihistamine and INS in patients with seasonal AR and asthma.1
If mast cell stabiliser eye drops are not effective in controlling eye symptoms, an eye drop containing both a mast cell stabiliser and antihistamine, such as olopatadine, can be prescribed.
A combined INS and antihistamine (fluticasone propionate/azelastine) spray may be prescribed but, although superior in reducing nasal itch to oral antihistamine, these do not alleviate itch at any other site. Intranasal and oral antihistamines can be used together.1
What are the side effects and are there any precautions that patients need to take with allergy medication?
Second-generation antihistamines (cetirizine, loratadine and fexofenadine) may still trigger drowsiness in some patients. Patients need to be aware of this and cautioned not to drive or operate machinery if they experience drowsiness. Fexofenadine is generally considered the least sedative of the second-generation antihistamine. In a large European pharmacovigilance study, 7 cetirizine, loratadine and fexofenadine were possibly linked to cardiac arrythmias and should be used with caution in those with cardiac issues; always consult with the patient’s cardiologist.
Related Article: Reliability of routine asthma test varies with time of day and season
Nasal irritation, sore throat and nose bleeds can occur in approximately 10% of patients using INS.1 Often this is due to the preservative benzalkonium chloride and switching to a benzalkonium free preparation, such as flixonase nasules, may help. Local side effects can be further reduced by ensuring patients use the correct technique to apply their nasal spray.
INS can cause systemic side effects, such as hypothalamic pituitary axis suppression and growth effects, but these are rare as the products are sprayed directly to the nostrils and systemic absorption is minimal. It remains good practice, however, to manage patients on the lowest dose of INS necessary to control symptoms and to monitor growth in children.1
Paediatric patients may experience neuropsychiatric side effects with the anti-leukotriene montelukast and parents must be counselled regarding this risk.8
When might someone need referral to a specialist for seasonal AR?
If, despite adherence to maximal pharmacotherapy of regular antihistamine, saline nasal rinsing and INS, a patient has persistent symptoms that affect their quality of life, nurses should arrange for them to be referred to a specialist allergy service.
Specific allergen immunotherapy, either sub-lingual or sub-cutaneous, may be indicated to desensitise the patient to pollen. Immunotherapy reduces the severity and frequency of AR symptoms and is an add-on treatment to be used alongside pharmacotherapy.1,9
Evidence suggests immunotherapy can modify AR and provide long-term relief of symptoms following discontinuation9. Allergen immunotherapy must be undertaken under specialist supervision; the BSACI has a helpful ‘find an allergy clinic’ service.
Katherine Knight is an ANP specialising in allergy and working in children’s allergy at the Allergy Centre of Excellence in London
References
- Scadding G, Kariyawasam H, Scadding G et al. BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007). Clin Exp Allergy 2017;47:856–889
- Papapostolou G, Kiotseridis H, Romberg K et al. Cognitive dysfunction and quality of life during pollen season in children with seasonal allergic rhinitis. Pediatr Allergy Immunol2021; 32(1):67-76
- Brozek J, Bousquet J, Agache I et al. Allergic rhinitis and its impact on asthma (ARIA) guidelines-2016 revision. J Allergy Clin Immunol 2017; 140(4):950-958
- Tohidinik H, Mallah N and Takkouche B. History of allergic rhinitis and risk of asthma; a systematic review and meta-analysis. World Allergy Organ J 2019;12(10):100069
- Dykewicz M, Wallace D, Amrol D et al. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol 2020;146(4): 721-767
- Gutiérrez-Cardona N, Sands P, Roberts G et al. The acceptability and tolerability of nasal douching in children with allergic rhinitis: A systematic review. Int J Pediatr Otorhinolaryngol 2017;98:126-135
- Poluzzi E, Raschi E, Godman B, et al. Pro-arrhythmic potential of oral antihistamines (H1): combining adverse event reports with drug utilization data across Europe. PLoS One 2015;10:e0119551
- Lo D and Quint J. Neuropsychiatric side effects of montelukast: time to change prescribing practice? 2025;80:1-2
- Zielen S, Devillier P, Henrich J et al. Sublingual immunotherapy provides long term relief in allergic rhinitis and reduces the risk of asthma: A retrospective, real-world database analysis. Allergy 2017;73(1):165-177
Related Article: How asthma management is changing – what nurses need to know
Further reading and resources
Allergy UK website: https://www.allergyuk.org/
BSACI website: https://www.bsaci.org/
NICE CKS. Topics: Allergic rhinitis
