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Allergic rhinitis - Management
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How can different allergens be avoided?
- Advise all people requiring step-up treatment about allergen avoidance. For people with:
- Grass pollen allergen: advise avoiding walking in grassy open spaces, particularly during the early morning, evening, and night, when pollen counts are at their highest, and to keep windows shut in cars and buildings. Advise changing car pollen filters with each service, if these are fitted.
- Confirmed house dust mite allergy inadequately controlled by drug treatment:
- For people who want to try house dust mite avoidance measures, advise fitting mattresses and pillows with house dust mite impermeable covers; use synthetic pillows and acrylic duvets, and keep furry toys off the bed. Wash all bedding and furry toys at least once a week at high temperatures. If possible, choose wooden or hard floor surfaces instead of carpets. Blinds that can be wiped clean should be fitted instead of curtains. Surfaces should be wiped regularly with a clean, damp cloth.
- Confirmed animal allergy: advise that ideally the animal should not be allowed in the house. When this is not acceptable, advise restricting their presence to the kitchen.
Basis for recommendation
- These recommendations are based on expert opinion included in guidelines for the management of allergic rhinitis provided by the British Society for Allergy and Clinical Immunology [Scadding et al, 2008]. There is a lack of good-quality trials examining the effect of house dust mite avoidance techniques in controlling the symptoms of allergic rhinitis.
- A Cochrane review of allergen avoidance techniques in the control of perennial allergic rhinitis found [Sheikh et al, 2007b]:
- Seven relevant randomized controlled trials, of which two trials were of good quality and five small trials were of poor quality.
- Of the interventions investigated, the authors found limited evidence that the use of acaricides and extensive bedroom-based environmental control programs may reduce symptoms of perennial allergic rhinitis caused by house dust mite.
What treatment can I offer if there is inadequate benefit with current treatment?
- For people taking oral antihistamines add in an intranasal corticosteroid and review after 2 to 4 weeks.
- For people taking an intranasal corticosteroid, ensure they are using their medication correctly. Step up to the maximum licensed dose of intranasal corticosteroid, and review after 2 to 4 weeks.
- For people with residual symptoms on a maximum licensed dose of intranasal corticosteroid, continue with treatment and:
- If there is persistent nasal itch, sneezing, rhinorrhoea, or allergic conjunctivitis add in an oral antihistamine.
- If rhinorrhoea persists despite combined use of intranasal corticosteroid and antihistamine add in intranasal ipratropium.
- If nasal blockage is a problem prescribe an intranasal decongestant for up to 7 days.
- For people requiring rapid resolution of severe symptoms impairing their quality of life, start or continue treatments to control symptoms long–term and consider prescribing a short course of oral corticosteroids for 5–10 days. Experts recommend prednisolone 20–40 mg a day in adults, and 10 mg a day in children.
- Refer people with persistent symptoms on maximal medical therapy for specialist assessment and management.
Additional information
Nasal spray technique [Scadding et al, 2008]:
- Gently blow the nose to try and clear.
- Shake the bottle well.
- Close off one nostril and put the nozzle in the other directing it away from the midline. Tilt head forward slightly and keep the bottle upright.
- Squeeze a fine mist into the nose while breathing in slowly. Do not sniff hard.
- Breathe out through the mouth.
- Take a second spray in the same nostril then repeat this procedure for the other nostril.
- Nasal drop technique [ABPI Medicines Compendium, 2004; ABPI Medicines Compendium, 2005b]:
- Gently blow the nose to try and clear.
- Shake the container well.
- Tilt the head backwards.
- Place the drops in the nostril (squeeze the container gently if necessary).
- Keep the head tilted and sniff gently to let the drops penetrate.
- Repeat for the other nostril if required.
- See Prescribing information for more information about the profiles of the recommended drugs.
Basis for recommendation
- Basis for recommending intranasal corticosteroids:
- Good evidence indicates that intranasal corticosteroids are the most effective treatment option for all-round symptom relief of allergic rhinitis.
- Basis for recommending oral corticosteroids for severe symptoms:
- Basis for recommending antihistamines for people preferring 'as-required' treatment for occasional symptoms:
- This is a pragmatic recommendation supported by experts, based on evidence of the comparative efficacy of oral antihistamines compared with other treatments for allergic rhinitis.
- Basis for recommending intranasal ipratropium bromide:
- Randomized controlled trials that have shown that it is effective in controlling watery nasal discharge [ARIA, 2001a].
- Basis for recommending an intranasal decongestant:
- Many experts consider that in the short term, intranasal decongestants are effective in the treatment of nasal obstruction [ARIA, 2001a; Scadding et al, 2008].
- Basis for NOT recommending leukotriene receptor antagonists:
- Experts do not recommend their use as first–line treatment for allergic rhinitis. Feedback from some expert reviewers supports their use as an add on treatment for people with allergic rhinitis and asthma when symptoms are poorly controlled with other treatments. However, there is a lack of evidence for their effectiveness as an add on treatment and their clinical role remains uncertain.
What follow-up advice can I give to someone on treatment with well controlled symptoms of allergic rhinitis?
- Advise people who have achieved adequate control of their symptoms with drug treatment that they should continue with treatment until they are no longer likely to be exposed to the suspected allergen:
- For people allergic to house dust mites and people allergic to pets that remain in their homes, symptoms are usually present throughout the year, requiring ongoing treatment.
- For people allergic to tree pollens, treatment is usually required from early to late spring.
- For people allergic to grass pollens, treatment is usually required from late spring to early summer.
- Advise people who have recurrent episodes of allergic rhinitis controlled by intranasal corticosteroids to restart treatment at least 7 days before re-exposure to allergen. When the time of re–exposure to antigen is uncertain, such as the start of the pollination season, start treatment several weeks before the most likely time of re–exposure.
Basis for recommendation
These recommendations are from expert opinion and are pragmatic in nature [ARIA, 2001b].
Prescriptions
Non-sedating oral antihistamines
Age from 2 years to 5 years 11 months
Cetirizine s/f solution: 5mg once a day
Cetirizine 1mg/ml oral solution sugar free
Take one 5ml spoonful once a day.
Supply 150 ml.
Loratadine syrup: 5mg once a day
Loratadine 5mg/5ml oral solution
Take one 5ml spoonful once a day.
Supply 150 ml.
Age from 6 years to 11 years 11 months
Cetirizine s/f solution: 10mg once a day
Cetirizine 1mg/ml oral solution sugar free
Take two 5ml spoonfuls once a day.
Supply 300 ml.
Loratadine syrup: 10mg once a day
Loratadine 5mg/5ml oral solution
Take two 5ml spoonfuls once a day.
Supply 300 ml.
Age from 12 years onwards
Cetirizine tablets: 10mg once a day
Cetirizine 10mg tablets
Take one tablet once a day.
Supply 28 tablets.
Loratadine tablets: 10mg once a day
Loratadine 10mg tablets
Take one tablet once a day.
Supply 28 tablets.
Fexofenadine tablets: 120mg once a day
Fexofenadine 120mg tablets
Take one tablet once a day.
Supply 30 tablets.
Intranasal antihistamine
Age from 5 years onwards
Azelastine 140microgram (0.1%) nasal spray
Azelastine 140micrograms/actuation nasal spray
Spray once into each nostril twice a day when required.
Supply 1 spray.
Intranasal corticosteroid sprays
Age from 4 years to 11 years 11 months
Fluticasone 50microgram nasal spray (4 years to 11 years 11 months)
Fluticasone 50micrograms/actuation nasal spray
Spray once into each nostril each morning.
Supply 1 spray.
Age from 5 years to 13 years 11 months
Flunisolide 25microgram nasal spray (5 years to 13 years 11 months)
Flunisolide 25micrograms/actuation nasal spray
Spray once into each nostril up to three times a day.
Supply 1 spray.
Age from 6 years to 11 years 11 months
Mometasone 50microgram nasal spray (6 years to 11 years 11 months)
Mometasone 50micrograms/actuation nasal spray
Spray once into each nostril once a day.
Supply 1 spray.
Triamcinolone 55microgram nasal spray (6 years to 11 years 11 months)
Triamcinolone 55micrograms/actuation nasal spray
Spray once into each nostril once a day.
Supply 1 spray.
Age from 6 years onwards
Beclometasone 50microgram nasal spray
Beclometasone 50micrograms/actuation nasal spray
Spray twice into each nostril twice a day.
Supply 1 spray.
Age from 12 years onwards
Budesonide 64microgram nasal spray
Budesonide 64micrograms/actuation nasal spray
Spray once into each nostril twice a day.
Supply 1 spray.
Fluticasone 50microgram nasal spray (12 years onwards)
Fluticasone 50micrograms/actuation nasal spray
Spray twice into each nostril each morning.
Supply 1 spray.
Mometasone 50microgram nasal spray (12 years onwards)
Mometasone 50micrograms/actuation nasal spray
Spray twice into each nostril once a day.
Supply 1 spray.
Triamcinolone 55microgram nasal spray (12 years onwards)
Triamcinolone 55micrograms/actuation nasal spray
Spray twice into each nostril once a day.
Supply 1 spray.
Age from 14 years onwards
Flunisolide 25microgram nasal spray (14 years onwards)
Flunisolide 25micrograms/actuation nasal spray
Spray twice into each nostril twice a day.
Supply 1 spray.
Intranasal corticosteroid drops
Age from 2 years onwards
Betamethasone 0.1% nose drops
Betamethasone 0.1% ear/eye/nose drops
Put two drops into each nostril twice a day.
Supply 10 ml.
Age from 16 years onwards
Fluticasone 400microgram nose drops
Fluticasone 400microgram unit dose nasal drops
Put six drops into each nostril once or twice a day.
Supply 28 ml.
Intranasal decongestants - for nasal blockage (short term)
Age from 2 years onwards
Ephedrine 0.5% nose drops
Ephedrine 0.5% nasal drops
Put one to two drops into each nostril up to four times a day when required for nasal blockage. Do not use for more than 7 days.
Supply 10 ml.
Age from 6 years to 11 years 11 months
Xylometazoline 0.05% nose drops
Xylometazoline 0.05% nasal drops
Put one to two drops into each nostril once or twice a day when required for nasal blockage. Do not use for more than 7 days.
Supply 10 ml.
Age from 12 years onwards
Xylometazoline 0.1% nose drops
Xylometazoline 0.1% nasal drops
Put two to three drops into each nostril 2 to 3 times a day when required for nasal blockage. Do not use for more than 7 days.
Supply 10 ml.
Xylometazoline 0.1% nasal spray
Xylometazoline 0.1% nasal spray
Spray once into each nostril 2 to 3 times a day when required for nasal blockage. Do not use for more than 7 days.
Supply 10 ml.
Oral steroid course: children
Age from 2 years to 11 years 11 months
Prednisolone soluble tablets: 10mg each morning for 5 days
Prednisolone 5mg soluble tablets
Take two tablets each morning (as a single dose) for 5 days.
Supply 10 tablets.
Prednisolone soluble tablets: 10mg each morning for 7 days
Prednisolone 5mg soluble tablets
Take two tablets each morning (as a single dose) for 7 days.
Supply 14 tablets.
Prednisolone soluble tablets: 10mg each morning for 10 days
Prednisolone 5mg soluble tablets
Take two tablets each morning (as a single dose) for 10 days.
Supply 40 tablets.
Oral steroid course: adults
Age from 16 years onwards
Prednisolone e/c tablets: 30mg each morning for 5 days
Prednisolone 5mg gastro-resistant tablets
Take six tablets each morning (as a single dose) for 5 days.
Supply 30 tablets.
Prednisolone tablets: 30mg each morning for 5 days
Prednisolone 5mg tablets
Take six tablets each morning (as a single dose) for 5 days.
Supply 30 tablets.
Prednisolone e/c tablets: 30mg each morning for 7 days
Prednisolone 5mg gastro-resistant tablets
Take six tablets each morning (as a single dose) for 7 days.
Supply 42 tablets.
Prednisolone tablets: 30mg each morning for 7 days
Prednisolone 5mg tablets
Take six tablets each morning (as a single dose) for 7 days.
Supply 42 tablets.
Prednisolone e/c tablets: 30mg each morning for 10 days
Prednisolone 5mg gastro-resistant tablets
Take six tablets each morning (as a single dose) for 10 days.
Supply 60 tablets.
Prednisolone tablets: 30mg each morning for 10 days
Prednisolone 5mg tablets
Take six tablets each morning (as a single dose) for 10 days.
Supply 60 tablets.
Ipratropium bromide 0.03%(21mcg) nasal spray for rhinorrhoea
Age from 12 years onwards
Ipratropium 0.03% (21mcg) nasal spray for watery rhinorrhoea
Ipratropium bromide 21micrograms/actuation nasal spray
Spray twice into each nostril 2 to 3 times a day.
Supply 1 spray.
Sodium cromoglicate (to consider in children/pregnant women)
Age from 2 years onwards
Sodium cromoglicate 4% nasal spray
Sodium cromoglicate 4% nasal spray
Spray once into each nostril 2 to 4 times a day.
Supply 1 spray.
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