Perennial Allergic Rhinitis

Allergic Rhinitis/Conjunctivitis (perennial/non-seasonal)

 

When to consider referral

 

Referral Criteria

 

1.    Perennial symptoms that are severe and resistant to treatment (when combination treatment at maximum doses has been attempted for at least 3 months).

 

 

Primary care management prior to referral

 

1.    Exclude red flag features

a.    Unilateral symptoms, polyps, persistent blood stained discharge or persistent purulent discharge – consider referral to ENT.

2.    Mild symptoms should be treated with oral non-sedating antihistamines (cetirizine 10mg, loratadine 10mg, or fexofenadine 180mg) once daily. If required a higher dose of up to 3 times per day can be tried; this is above the licensed dose but there is good safety data and it may be effective in some people.

3.    Moderate-severe symptoms should be treated with intranasal antihistamine (eg azelastine/Rhinolast) if available, and/or an intranasal corticosteroid (eg Beconase, two sprays into each nostril twice daily. Consider trying alternatives, eg Nasonex, Avamys or Dymista) in addition to non-sedating antihistamines.  Consistent daily use of intranasal sprays is vital, given maximal effect may not be apparent for at least two weeks.

4.    Moderate-severe symptoms should be treated with intranasal corticosteroid (eg Beconase, two sprays into each nostril twice daily; consider alternative, eg Nasonex, Avamys or Dymista) in addition to non-sedating antihistamines.  Consistent daily use of intranasal use is vital, given maximal effect may not be apparent for at least two weeks.

a.    Training in appropriate nasal spray technique essential. Guidance is given at http://www.nationalasthma.org.au/uploads/publication/intranasal-corticosteroid-spray-technique.pdf

 

5.    Systemic corticosteroids (in addition to intranasal corticosteroid) at doses of 15-20mg for a maximum of 5 days as a one-off course can be used for severe symptoms uncontrolled on conventional therapy, to control symptoms during important periods (eg exams or other major events).

 

6.    Topical cromoglicate and nedocromil eyedrops are useful to manage allergic conjunctivitis.

 

7.    Consider requesting specific IgE to common or suspected precipitants (most commonly house dust mite or pets if exposed).

 

8.    Consider a concomitant diagnosis of asthma and manage according to guidelines

 

Avoid sedating antihistamines, depot corticosteroids, and chronic use of decongestants.

Treatment failure should prompt a review of the diagnosis, compliance with therapy (regular therapy is more effective than “as required” treatment), and intranasal corticosteroid technique.

 

Differential diagnosis

-       Seasonal rhinitis (symptoms only in pollen season spring/summer)

-       Infective rhinosinusitis

-       Non-allergic (eg hormonal, drug-induced, vasomotor) rhinitis

 

For more information see

http://www.guidelines.co.uk/eye_ear_nose_throat_bsaci_rhinitis

http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2222.2007.02888.x/pdf

 

Information required with referral

 

Clinical history, background of treatment tried, any investigations performed.

 

 

Clinic options available

 

We have no Choose and Book slots available – we review and triage all referrals ourselves and allocate clinics appropriately.