Managing allergic rhinitis

As allergy rates skyrocket nurses are playing an increasingly important role in allergy testing, patient education, medication compliance and liaison with GPs.

Allergic rhinitis is one of the most common allergic diseases, and yet is often trivialised in Australia.

It can have a significant impact on the patient, is often poorly managed and if left untreated can lead to poly-sensitisation and the development of allergic asthma.

It is a scenario Eddie Weber, clinical nurse coordinator at the Allergy, Asthma and Clinical Immunology Service, Alfred Hospital, Melbourne knows too well, as he sees growing numbers of patients presenting with severe allergic rhinitis at his hospital’s clinic. “The majority of patients presenting to our clinic with severe allergic rhinitis have been referred by their GP. They have tried other medical treatments but these have all failed. They are referred to our clinic to properly diagnose their allergy and to look at the possibility of allergen immunotherapy treatment,” said Mr Weber.

“While allergen immunotherapy is reserved for moderate-to-severe patients, most people are surprised to learn that people suffering from allergic rhinitis for four days a week, for four weeks or more a year qualify as being moderate to severe.

“People with severe allergic rhinitis who rely on symptomatic treatments such as nasal sprays and antihistamines often find the treatments simply don’t control their symptoms.

“Nurses in our clinic play a critical role in educating the patient about treatments, supporting the clinical consultants and liaising with their GP for proper ongoing care,” he said.

“It is very satisfying to really help patients who previously thought they just had to put up with allergic rhinitis,” said Mr Weber.

Understanding allergic rhinitis

Allergic rhinitis, also known as hay fever, occurs when the upper airways and eyes become inflamed. It is an abnormal reaction to airborne allergens such as dust mites, pollens, animals and moulds.

Allergic rhinitis is no a trivial disease. The rates of allergic rhinitis are increasing, affecting more than three million Australians and 400 million people worldwide. Allergic rhinitis has a significant impact on quality of life and more than 70 per cent of sufferers say it limits their way of life. People suffering from allergic rhinitis can experience sleep disorders, fatigue, irritability, lack of concentration, poor school and work performance. It has also been linked to chronic health conditions such as allergic asthma, sinusitis, ear infections, conjunctivitis, anxiety and depression.

The full impact of allergic rhinitis should not be underestimated.

A major consequence of allergic rhinitis is an increased risk of developing asthma. Asthma is three times more common in those with allergic rhinitis than in the general population and over 80 per cent of allergic asthmatics have allergic rhinitis6.

The Allergic March

Allergies can begin at any age, but usually begin in childhood and can change and develop throughout life. Some people may grow out of an allergy, while others may develop more allergies.

A child may begin with eczema that may be associated with a food allergy, which may then progress to a respiratory allergy, such as allergic asthma or allergic rhinitis; this is known as the allergic march.

Getting the diagnosis right

Many allergic rhinitis sufferers self-diagnose and self-medicate which may not reduce their allergy symptoms effectively, be expensive and cause unwanted side effects. To effectively treat a patient’s allergy you need to pinpoint the allergens causing the allergic reaction1.

At the Alfred Clinic, patients receive a full assessment. This involves taking the patient and family history, conducting a physical examination, and if required, allergy testing to confirm what allergens are causing their symptoms.

‘It’s important when undertaking an assessment of a patient’s condition that it is done in the context of the patient’s clinical history and their symptoms on exposure to the allergens’, said Mr Weber.

Mr Weber, if required, will perform skin prick tests. Drops of the suspected allergens are placed on the patient’s forearm to determine an allergic reaction. This test can be performed in the clinic and results are available within 20 minutes2. Serum blood tests for allergen specific IgE, also called RAST tests, may be conducted as part of the overall assessment of a patient’s allergic disease.

“In Victoria, we see grass pollens, and particularly rye grass, as the dominant seasonal allergen. European dust mites are the dominant perennial allergen”, said Weber.

“Avoiding allergens is often the first step considered for controlling allergies, but avoiding pollens is virtually impossible,” Weber said.

Symptomatic treatments

There are many symptomatic treatments available both over the counter and through prescription. They can be effective for those with mild to moderate allergic rhinitis symptoms. However, they may not be adequate for those with persistent, severe symptoms. Approximately 60 per cent of severe allergic rhinitis patients have reported as poor, bad or very bad the control of their disease with symptomatic treatments alone.

The most common type of symptomatic treatments for allergic rhinitis include:
* Antihistamines, recommended as the first-line therapy for mild intermittent allergic rhinitis taken as nasal drops or in tablet form;
* Intranasal corticosteroids, first-line treatment in patients with moderate to severe allergic rhinitis, can be very useful particularly for those with more persistent symptoms, and those with nasal congestion. They are administered intra-nasally or inhaled, and
* Beta-2-mimetics, a symptomatic treatment for asthma and their main effect is to relieve bronchial spasms.

Allergen immunotherapy

Allergen immunotherapy is the only treatment that treats the cause of respiratory allergic diseases. It is suitable for moderate to severe respiratory allergy sufferers who have not been able to adequately control their condition with symptomatic treatments.

Allergen immunotherapy helps re-educate the body’s immune system. Allergen immunotherapy can reduce or stop allergic symptoms, reduce or stop the use of symptomatic drugs even during the first year of treatment, prevent the onset of new allergies, also known as poly-sensitisation, stop the development of allergic rhinitis into allergic asthma and significantly improve a patient’s quality of life.

A critical part of Mr Weber’s role is to provide advice and guidance to his patients who have been selected as suitable for allergen immunotherapy treatment. The treatment is a long term commitment. It is recommended that allergen immunotherapy continues for about three years to get the maximum benefit.

“Patient selection is fundamental to the success of allergen immunotherapy. It is suitable for those with persistent and severe symptoms, where the allergen is difficult to avoid and where symptomatic treatments haven’t worked. We want to get the best results for our patients and not waste their time and money”, said Mr Weber.

“My role has a large educative component. Motivation and adherence can be issues and so I talk with patients about their treatment schedule and what they should expect throughout the course of their treatment.”

Mr Weber also liaises closely with referring GPs. After the initial consultation and first administration of allergen immunotherapy treatment, patients are usually referred back to their GPs for ongoing management.

Allergen immunotherapy can be administered as drops or tablets under the tongue, known as sublingual or by injection, known as subcutaneous. Mr Weber will administer the first drops or tablets or give a patient their first injection. The patients are then monitored to check for any adverse reactions which are usually mild.

A more convenient treatment, patients can take the sublingual drops or tablets at home on a daily basis. This suits patients who do not like injections, particularly children. Ongoing subcutaneous injections can be administered by the patient’s referring medical practitioner usually on a monthly basis.

1 Baumgart, K., ‘Allergic Rhinitis’, Part 2, Clinical Update, Medical Observer, 28 September 2012.
2 ‘Skin Prick Testing for the diagnosis of allergic disease’, A manual for practitioners, Australasian Society of Clinical Immunology and Allergy (ACSIA), Revised 2008.

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