Advice on the Management of Adults and children over 12 years with Allergic Rhinitis and non-allergic rhinitis

Publication: 06/10/2020  
Next review: 06/10/2025  
Clinical Guideline
CURRENT 
ID: 4133 
Approved By: LAPC 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Advice on the Management of Adults and children over 12 years with Allergic Rhinitis and non-allergic rhinitis

This pathway is intended for use by healthcare professionals who see patients with allergic and non-allergic rhinitis.

Background

Rhinitis describes inflammation of the nasal mucosa but is clinically defined by the symptoms of nasal discharge, itching sneezing and nasal blockage or congestion.

Rhinitis can be classified as allergic, non-allergic infective as well as mixed forms.

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a. Allergic rhinitis

Allergic rhinitis affects 10-15% of children and 26% of adults in the UK. It is often subject to under - recognition and poor management. This is important as allergic rhinitis affects the quality of life, school and work attendance. Asthma is an important co-morbidity and rhinitis in not only a risk factor for subsequent asthma but 80% of asthma sufferers according to ARIA (Allergic rhinitis and its impact on asthma) guidelines have concomitant rhinitis, poor control of which is a risk factor for asthma exacerbations

The classification of allergic rhinitis is based on the timing, frequency, severity and persistence of the symptoms. It can be seasonal, perennial, intermittent, and persistent. The symptoms may be classed as mild (having no impact on quality of life), or moderate/severe, in which the symptoms are troublesome and impacting on daily activities and sleep.

In the ARIA guidelines, the following outcomes were deemed to be important to patients. Nasal and ocular symptoms, quality of life, work/school performance and adverse effects.

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b. Non-allergic rhinitis

These are patients with symptoms of rhinitis but without any identifiable allergic trigger. It is a diagnosis of exclusion in patients negative for systemic IgE where other causes of rhinitis have been rules out.

Note Occupational rhinitis can be either allergic or non-allergic. The early identification of a causative occupational agent and the avoidance of exposure are important for the prevention of a progression from occupational rhinitis to occupational asthma.

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Lifestyle Advice and non-pharmacological therapies

Advise avoidance of the patient from the allergy when known. E.g. for grass pollen allergy, avoid walking in open grassy spaces (especially if the grass is recently mown), keep windows closed and shower and wash hair if exposed. For house dust mite, use synthetic pillows, wash bedding weekly at a high temperature. For occupational rhinitis it is important to wear protective clothing, and work in well ventilated areas.

Sodium chloride 0.9% nasal irrigation has limited evidence but may provide symptom relief, is inexpensive and is unlikely to cause harm and is recommended by ARIA. As per NHS England guidance for mild or moderate rhinitis patients should be encouraged to buy this over-the-counter.

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Pharmacotherapy treatment from BSACI (British Society of Allergy and Clinical Immunology) guideline (Revised edition 2017)

Allergen and avoidance treatment can be difficult and many rhinitis sufferers continue to have persistent symptoms. A stepped pharmacological approach should be undertaken, and often a combination of treatment is required for more severe disease.

Important points

  1. Always check techniques of nasal sprays. Asthma UK video on how to use a nasal spray. https://www.asthma.org.uk/advice/inhaler-videos/nasal-spray/
  2. Enhanced patient education, see British Society for allergy and clinical Immunology Improving allergy care: https://www.bsaci.org/patients/most-common-allergies/rhinitis/
  3. Need to control environment as much as possible, e.g. How to improve your air quality
    https://www.allergyuk.org/information-and-advice/conditions-and-symptoms/320-improving-your-indoor-air-quality#download_access

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Treatment Options

Unfortunately the evidence for recommendations is generally weak and for the ARIA guidelines a Delphi method was used, where a panel of experts provide guidelines. The ARIA guidelines recommends:-

  • The use of intranasal corticosteroids in the treatment of both allergic and non-allergic rhinitis is more effective than intranasal antihistamines, alone.
  • Combined intranasal antihistamine and intranasal corticosteroids may act faster than intranasal corticosteroids alone in both allergic and non-allergic rhinitis..
  • Combined intranasal steroids and intranasal antihistamine is more effective than an intranasal antihistamine alone.
  • Little benefit shown between intranasal corticosteroid and oral antihistamine versus intranasal corticosteroid alone.
  • No strong recommendation between oral antihistamine and intranasal antihistamine (patient preference)
  • Leukotriene receptor antagonists may have a place in allergic rhinitis but not non-allergic rhinitis

Therefore despite the limited evidence both the ARIA and BSACI agree regarding the place of intra-nasal treatment in the treatment of rhinitis.

Drug

Place in therapy

Comments

Oral second generation antihistamines

First line mild to moderate intermittent and mild persistent rhinitis

Addition to intranasal steroids for moderate to severe persistent rhinitis uncontrolled on topical intranasal steroids alone. Note Combination less effective than combined intranasal antihistamine/steroids

Topical H1 antihistamines - nasal

First line for mild to moderate intermittent and mild persistent rhinitis.

Superior to oral antihistamines in attenuating rhinitis symptoms and decreasing nasal obstruction. Rapid action 15 minutes. No advantage combing with oral antihistamine.

Intranasal steroids

First line therapy for moderate to severe persistent symptoms. First line if presenting with severe nasal obstruction.

For children mometasone furoate, fluticasone furoate and fluticasone propionate as systemic absorption negligible. Maximum effects may take up to two weeks

Combined intranasal steroid and antihistamine

Should be used in patients when symptoms remain uncontrolled on mono-therapy with intranasal steroids or oral antihistamine or combined oral antihistamine plus intranasal steroids therapy.

More effective than either product used alone. May result in control of symptoms several days earlier. All symptoms significantly improved.

Oral corticosteroids

Only as short term rescue medication during severe exacerbation despite compliance on conventional therapy.

For adults 30mg od
For children 0.5mg/kg up to a ceiling of 30mg od
For 5 days

Intranasal decongestions

Increase nasal patency before douching or intranasal administration of steroids

Short term use only, evidence level poor.

Anti-leukotrienes.

May be useful in patients with asthma and allergic rhinitis

 

Topical anti-cholinergic
(Ipratropium)

As an add on in patients with watery rhinorrhoea despite compliance with intra nasal steroids plus antihistamine

 

Sodium cromoglycate nasal spray

Children and adults with mild symptoms only and in patients unable to take other medication e.g. pregnant women.

 

Immunotherapy treatment

Seek specialist advice

Provenance

Record: 4133
Objective:
Clinical condition:

Allergic Rhinitis and non-allergic rhinitis

Target patient group:
Target professional group(s): Primary Care Doctors
Secondary Care Doctors
Pharmacists
Primary Care Nurses
Secondary Care Nurses
Adapted from:

Evidence base

  1. Scadding et al. BSACI guidelines for the diagnosis and managemet of allergic and non-allergic rhinitis (Revised Edition 2017 first edition 2007). Clin. Exp Allergy 2017;47:856-889
  2. Brozek at al. Allergic rhinitis and its impact on asthma (ARIA) guidelines 2016 revision. J. allergy clin immunol 2017. 140 (4) 950-58
  3. CKS NICE allergic rhinitis September 2018 accessed 6/20 https://cks.nice.org.uk/allergic-rhinitis

Approved By

LAPC

Document history

LHP version 1.0

Related information

Not supplied