Allergic rhinitis: more than a sniffle & a sneeze

woman sneezing in field

With the availability of over-the-counter treatments for allergy symptoms, many people choose to self-treat. Yet, often this results in sub-optimal management

Several studies have shown that allergic rhinitis (hay fever) can have a huge burden on quality of life. Hence, it should not be considered a nuisance, as it often is by patients, but rather a significant health problem.

Connie Katelaris, professor of immunology and allergy at the University of Western Sydney, explains, “Chronic or severe allergic rhinitis causes significant nasal construction, which can greatly impact a person’s ability to sleep properly and this can leave the person tired, irritable and unable to concentrate. Allergic rhinitis also predisposes people to sinus infections, which can become a chronic issue.”

Sinthia Bosnic-Anticevich, respiratory pharmacist and professor at the University of Sydney, says, “There’s a substantial amount of data to show that the burden of allergic rhinitis is very high.

“However, patients often don’t realise that some of the things they‘re experiencing are related to their allergic rhinitis. For example, work performance can be affected by poor concentration or impaired cognitive function as a result of sleep disturbance.”

Prof Katelaris adds, “For those people with asthma, poorly controlled allergic rhinitis can exacerbate asthma symptoms and result in the need for more medication.

“These associated health risks, not to mention the general irritability caused by allergic rhinitis, can have a real impact on an individual’s quality of life.”

While several studies have outlined the negative effects of allergic rhinitis symptoms on quality of life, it’s also come to light the fact that many people with allergic rhinitis do not seek a proper diagnosis. Instead of seeking medical advice from their GP, they choose to self-treat with over-the-counter medicines.

Why do people choose to self-manage?

“Between 60–70% of people self-select treatment for allergic rhinitis. In most cases, the reason for this is simply because they feel don’t need to ask for advice. From their perspective, they believe themselves to be well equipped to make a selection,” explains Prof Bosnic-Anticevich.

“They may have spoken to other people or seen an advertisement on television and they believe the way in which they’re self-treating works well for them. They don’t have a compelling reason to discuss their treatment choice with the pharmacist. However, this makes it difficult as it means pharmacists need to be proactive”.

While the tendency to self-select allergic rhinitis treatments is high, many people have sub-optimal control of their symptoms. Biljana Cvetkovski from the Woolcock Institute has investigated allergic rhinitis from the perspective of the patient, which may provide pharmacists with some useful insights.

“Many people with allergic rhinitis feel confident in their ability to manage their symptoms, yet they frequently underestimate the severity of their condition and its impact on their quality of life. Only 15% of people with allergic rhinitis that self-select medicine from a pharmacy make an optimal choice, highlighting the extent of the burden within the community.

“Through understanding patient perspectives and the factors that influence their allergic rhinitis decision making, pharmacists, among other healthcare professionals, may be able to identify ways to assist people to improve their management.

“For example, our investigation found that although healthcare professionals were readily providing advice on allergic rhinitis medication, very few were following up and reviewing the treatment.”

She adds, “When it comes to symptom relief, our participants reported a high tolerance to their symptoms and were satisfied with just a small reduction in their severity, not realising that they can expect even further improvement in their symptoms if their allergic rhinitis management was optimised.”

Prof Bosnic-Anticevich says, “If people think that all they need is a little improvement, they’ll likely become less concerned with treatment and this is why they continue to self manage.”

Supporting self-treatment

An important component of effective treatment is firstly receiving a correct diagnosis, which seems to be a stumbling block for many people with allergic rhinitis.

“In general, across all the studies we’ve conducted, only 50% of people with allergic rhinitis have obtained a doctor diagnosis. So there’s good chance that if the pharmacist is talking to a person who is self-selecting treatment for their nose, they have not been diagnosed with allergic rhinitis,” says Prof Bosnic-Anticevich.

Indeed, Ms Cvetkovski’s work identified people who had been treated for asthma before eventually being diagnosed with allergic rhinitis, as well as people who were assumed to have a cold or the flu.

“It’s really important for the pharmacist to be compelled to want to have the conversation with the person who comes in to select a treatment for their allergic rhinitis symptoms,” Prof Bosnic-Anticevich says.

“We know most people are self-managing, even though they have a choice to speak to the pharmacist.

Yet, if they don’t feel they need to talk to the pharmacist there’s going to be a bit of a barrier there. This is why the pharmacists themselves need to feel duty-bound to approach the patient. They also need to believe that, in most cases, they will be able to assist the patient in achieving a better outcome.

“If the patient already thinks they know how to treat their allergic rhinitis, pharmacists really need to hone in and encourage the person to think about things they haven’t thought about before.

“Asking patients how ‘bothersome’ their symptoms are can be useful. It’s been shown that in regards to allergic rhinitis, the response that patients give to this question can be a valid way of gaining an insight into the severity of their symptoms.

“Allergic rhinitis is a lot more complex than patients or pharmacists realise. Healthcare professionals are taught to respond to what the patient’s problem or disease status is, but if the person is not aware or realistic about the extent to which something is impacting them it makes it very difficult to treat.”

She adds, “From the research we’ve done, it appears that those people who come into pharmacy are likely to have moderate to severe allergic rhinitis symptoms. So there’s certainly an important role that pharmacy can play in helping people to avoid suboptimal treatment.”

“Also, interestingly, the data we collected from general practice revealed that only half the people who had asthma and allergic rhinitis had had the allergic rhinitis diagnosed by their doctor.

“It can be confusing for people who have an asthma flare-up to recognise whether it’s related to their nose or their lungs,” says Prof Bosnic-Anticevich.

Siobhan Brophy, CEO of National Asthma Council Australia, tells the AJP, “Approximately 15% of Australians have allergic rhinitis and approximately 10% have current asthma. However, asthma and allergic rhinitis frequently co-exist.

“Both rhinitis and asthma can be triggered by the same factors, whether allergic (house dust mite, pet allergens, pollen, cockroach) or non-specific (cold air, strong odours, environmental tobacco smoke). We know that at least 75% of patients with asthma also have rhinitis, although estimates vary widely. We also know that the presence of allergic rhinitis is associated with worse asthma control.”

Helping people to optimise allergy treatment and recommending they visit their GP if there are any symptoms that are suggestive of asthma (chest tightness, wheeze, shortness of breath) is an important role for pharmacy.

Treatment preference

With regards to treatment options, Ms Cvetkovski identified three predominant opinions. “Firstly, there were those with a preference to not medicate at all with the exception of a nasal saline wash or mist.

“Secondly, there were those who reluctantly medicate, only when they felt the symptoms had become intolerable.

“Thirdly, there was the group of participants who were willing to take any form of treatment in order to be symptom free.”

She explains that the first and second group had the underlying belief that medicines do not work, or that they had tried all options to no avail. Those who were willing to medicate tended to choose non-sedating oral antihistamines. Intranasal corticosteroids (INCS) were typically used at one time or another but not routinely, despite the fact they can give greater symptom control.

Only the group that medicated in order to be symptom free took medicine regularly and preventatively. However, regardless of the severity of symptoms or impact on quality of life, there was a strong preference for oral medicines.

“This was due to perceived ease of administration and use, portability, palatability, perceived effectiveness and onset of action,” explains Ms Cvetkovski.

“It can be quite challenging for healthcare professionals when recommending optimal treatments to their patients that may not necessarily align with their preferences. This is of particular concern in patients with moderate to severe allergic rhinitis who need to use an INCS. Understanding why the individual patient is averse to INCS and addressing their concerns is the best strategy in these circumstances.

“Sometimes it is as simple as teaching them correct intranasal inhaler technique and asking them to demonstrate use of the product following its purchase, to ensure it is being used optimally.

“The National Asthma Council website has some fantastic demonstration videos for all INCS brands and devices. It’s a great resource for pharmacists and their customers,” she advises.

According to the Australasian Society of Clinical Immunology and Allergy, alongside allergen avoidance, antihistamines (oral or intranasal) are the typical first-line treatment for mild and intermittent allergic rhinitis. They can be used with or without saline irrigation.

For mild and persistent allergic rhinitis or moderate to severe (whether intermittent or persistent) INCS are recommended as the first-line treatment. INCS can be used alone or in combination with antihistamine spray.

Prof Bosnic-Anticevich notes, “It’s very rare to see a preventer strategy happening in relation to allergic rhinitis. Traditionally we haven’t really had this as a big focus in pharmacy. Certainly, other chronic illnesses, such as diabetes, asthma and cardiovascular disease, have had long-term prevention and follow up strategies, but allergic rhinitis hasn’t been included in this.

“This may be because some people only experience allergic rhinitis seasonally, not every day of the year. Although during the key seasons we could consider implementing a more preventative approach.

“Also, I don’t think we were aware of how many people don’t just get their allergic rhinitis seasonally; they actually get it throughout the year.

“Allergic rhinitis is a significant chronic condition. Even if it is intermittent or seasonal, it’s still a chronic condition. It might be triggered at different times by different things, but it’s not going to go away. Certainly, we can take a more preventative and proactive approach to managing allergic rhinitis.” 

Confusing allergic rhinitis symptoms with coronavirus

It’s more likely that those living in Europe, which is going into spring, might mistake allergic rhinitis symptoms for coronavirus. However, it pays to be aware of the differences.

The World Health Organisation reports the common symptoms of coronavirus include:

  • Fever
  • Tiredness
  • Dry cough

Other symptoms include:

  • Shortness of breath
  • Aches and pains
  • Sore throat

According to the Australasian Society of Clinical Immunology and Allergy, symptoms of allergic rhinitis include:

  • Sneezing, itchy nose, sniffing, upward rubbing of the nose
  • Clear rhinorrhea
  • Nasal obstruction/congestion (e.g. nasal speech, mouth breathing, snoring)
  • Itchy throat, frequent need to clear the throat, which may result in coughing
  • Watery, itchy eyes (allergic conjunctivitis) which may occur in conjunction with allergic rhinitis or in isolation.

In addition, the WHO advises that very few people will report diarrhoea, nausea or a runny nose.

While there may be an overlap in symptoms such as coughing and a runny nose, it’s important to point out the following facts:

  • Fever and sore throat, which are common in people with coronavirus, are not typical symptoms of allergic rhinitis.
  • The itchy symptoms (affecting eyes, throat, nose and ears) associated with allergic rhinitis and not typical symptoms of coronavirus

Information sources

Cvetkovski B, Kritikos V, Tan R, et al. A qualitative investigation of the allergic rhinitis network from the perspective of the patient. npj Primary Care Respiratory Medicine. 2019;29:35.

Cvetkovski B, Kritikos V, Yan K, et al. Tell me about your hay fever: a qualitative investigation of allergic rhinitis management from the perspective of the patient. npj Primary Care Respiratory Medicine. 2018;28:3.

Allergic rhinitis clinical update. Australasian Society of Clinical Immunology and Allergy. 2017

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