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Allergic Rhinitis in Adults

This guideline applies to adults.

 

Introduction

  • Allergic rhinitis is common: prevalence of 26% in adults in the UK (2004)1.
     
  • It is typically lifelong; only 10% of children and young people outgrow the condition1.
     
  • Symptoms can have a significant impact on quality of life, mood, sleep, concentration and behaviour.
     
  • Differential diagnosis includes acute rhinitis, non-allergic rhinitis (idiopathic, environmental, hormonal, drug-induced, vasomotor), chronic rhinosinusitis, nasal foreign body, nasal malignancy.


 

Red Flag Features

  • Nasal malignancy

  • Unilateral nasal symptoms
     
  • Nasal foreign body, especially button/watch batteries

Not an exhaustive list.


 

Investigations

A therapeutic trial of treatment is considered the first investigation when the history is typical.


In perennial allergic rhinitis, consider requesting specific serum IgE to common or suspected precipitants i.e. house dust mites, animal dander.


In seasonal allergic rhinitis, specific testing is not required in the first instance as the treatment is the same regardless of cause.



 

Management Optimisation

For detailed information about medical management of allergic rhinitis see:

 

Key points:

  • Identify and eliminate allergens.
  • Encourage saline nasal irrigation.
  • Intranasal steroids are the most effective treatment if used correctly and regularly, see RMS guideline on the Nasal Steroid ladder:
    • Intranasal steroid + oral antihistamine is no more effective than an intranasal steroid alone1.
    • Intranasal steroid + intranasal antihistamine is more effective than an intranasal steroid alone1.
    • If seasonal, start intranasal steroids 2 weeks before symptom onset1.
    • Regular therapy is more effective than “as required”.
    • Avoid sedating antihistamines, depot corticosteroids, chronic use of nasal decongestants and systemically bioavailable intranasal steroids e.g. betamethasone.
  • Consider concomitant asthma and manage accordingly – treating allergic rhinitis will improve asthma.
  • Treatment failure should prompt a review of the diagnosis, compliance with treatment and intranasal steroid technique.
  • If an adult has severe, uncontrolled symptoms that are significantly affecting quality of life, consider prescribing a short course of oral corticosteroids to provide rapid symptom relief1.

 

Onset of action of medication groups used in the treatment of allergic rhinitis:


 

Advice and Guidance

Seek ENT Advice and Guidance for:

  • Diagnostic uncertainty
  • Suspected nasal malignancy
  • Unilateral nasal polyp
  • Nasal mass with concerning features or atypical appearance


 

Referral

Same-day Assessment

Nasal foreign body:

  • Button/watch batteries – if not confident/experienced to remove, send straight to ED.
  • Other types of nasal foreign body – ENT first on-call.

 

Allergy Referral to Immunology Derriford

  • Severe seasonal symptoms that are resistant to combination treatment at maximum doses throughout the season.
  • Severe perennial symptoms that are resistant to combination treatment at maximum doses for at least 3 months.

 

Exclusions

  • Referral to see if pets need re-housing
  • Requests for tests to prove that mould / old pet her is causing a problem in rental properties or another family member’s house

 

ENT Referral

Very limited surgical options for allergic rhinitis.

  • Persistent nasal symptoms, likely secondary to rhinosinusitis overlay:
    • not responding to an adequate trial of medication, and
    • fail to meet the criteria for allergy referral.

Children and young people, aged under 16 years – refer to Paediatric ENT Services.



 

Supporting Information

For professionals:

 

For patients:

 

References

  1. National Institute of Clinical Excellence. CKS: Allergic Rhinitis; January 2024
  2. Medicines for Children. Prednisolone for asthma; 2018

 

Page Review Information

Review date

04 July 2025

Next review date

04 July 2027

GP speciality lead

Dr Laura Vines, GP, RMS

Dr Melanie Schick, GP, RMS

Contributors

Ms Aileen Lambert, ENT Consultant Surgeon, RCHT

Dr Andrew Whyte, Consultant Allergist and Immunologist, Derriford

Dr Simon Bedwani, Consultant Paediatrician, RCHT