Symptoms in the Pharmacy :Respiratory Problems (13)

Allergic rhinitis

Seasonal allergic rhinitis (hay fever) affects 10–15% of people in the
UK and millions of patients rely on OTC medicines for treatment.
The symptoms of allergic rhinitis occur after an inflammatory
response involving the release of histamine which is initiated by allergens
being deposited on the nasal mucosa. Allergens responsible for
seasonal allergic rhinitis include grass pollens, tree pollens and fungal
mould spores. Perennial allergic rhinitis occurs when symptoms are
present all year round and is commonly caused by the house dust mite,
animal dander and feathers. Some patients may suffer from perennial
rhinitis which becomes worse in the summer months.
What you need to know

• Age (approximate)
• Baby, child, adult
• Duration
• Symptoms
• Rhinorrhoea (runny nose)
• Nasal congestion
• Nasal itching
• Watery eyes
• Irritant eyes
• Discharge from the eyes
• Sneezing
• Previous history
• Associated conditions
• Eczema
• Asthma
• Medication
• Significance of questions and answers

Age
Symptoms of allergic rhinitis may start at any age, although its onset is
more common in children and young adults (the condition is most
common in those in their twenties and thirties). There is frequently

a family history of atopy in allergic rhinitis sufferers. Thus children of
allergic rhinitis sufferers are more likely to have the condition. The
condition often improves or resolves as the child gets older. The age of
the patient must be taken into account if any medication is to be
recommended. Young adults who may be taking examinations should
be borne in mind, because treatment that may cause drowsiness is best
avoided in these patients.

Duration
Sufferers will often present with seasonal rhinitis as soon as the pollen
count becomes high. Symptoms may start in April when tree
pollens appear and the hay fever season may start 1 month earlier in
the south than in the north of England. Hay fever peaks between the
months of May and July, when grass pollen levels are highest and
spells of good weather commonly cause patients to seek the pharmacist’s
advice. Anyone presenting with a summer cold, perhaps of
several weeks’ duration, may be suffering from hay fever. Fungal
spores are also a cause and are present slightly later, often until
September.

People can suffer from what they think are mild cold symptoms for
a long period, without knowing they have perennial rhinitis.

The PRODIGY classification of allergic rhinitis:

 
Intermittent. Occurs less than 4 days per week or for less than 4
weeks
Persistent. Occurs more than 4 days per week and for more than
4 weeks
Mild. All of the following – normal sleep; normal daily activities,
sport, leisure; normal work and school; symptoms not troublesome
Moderate. One or more of the following – abnormal sleep; impairment
of daily activities, sport, leisure; problems caused at work or
school; troublesome symptoms
(Source: www.prodigy.nhs.uk)

Symptoms

 
Rhinorrhoea
A runny nose is a commonly experienced symptom of allergic rhinitis.
The discharge is often thin, clear and watery, but can change to a
thicker, coloured, purulent one. This suggests a secondary infection,
although the treatment for allergic rhinitis is not altered. There is no
need for antibiotic treatment.

Nasal congestion
The inflammatory response caused by the allergen produces vasodilatation
of the nasal blood vessels and so results in nasal congestion. Severe
congestion may result in headache and occasionally earache. Secondary
infection such as otitis media and sinusitis can occur .

Nasal itching
Nasal itching commonly occurs. Irritation is sometimes experienced
on the roof of the mouth.

Eye symptoms
The eyes may be itchy and also watery; it is thought these symptoms
are a result of tear duct congestion and also a direct effect of pollen
grains being caught in the eye, setting off a local inflammatory
response. Irritation of the nose by pollen probably contributes to eye
symptoms too. People who suffer severe symptoms of allergic rhinitis
may be hypersensitive to bright light (photophobic) and find that
wearing dark glasses is helpful.

Sneezing
In hay fever the allergic response usually starts with symptoms of
sneezing, then rhinorrhoea, progressing to nasal congestion. Classically,
symptoms of hay fever are more severe in the morning and in the
evening. This is because pollen rises during the day after being released
in the morning and then settles at night. Patients may also describe a
worsening of the condition on windy days as pollen is scattered, and a
reduction in symptoms when it rains, or after rain, as the pollen clears.
Conversely, in those allergic to fungal mould spores the symptoms
worsen in damp weather.

Previous history
There is commonly a history of hay fever going back over several
years. However, it can occur at any age, so the absence of any previous
history does not necessarily indicate that allergic rhinitis is not the
problem. The incidence of hay fever has risen during the last decade.
Pollution, particularly in urban areas, is thought to be at least partly
responsible for the trend.
Perennial rhinitis can usually be distinguished from seasonal rhinitis
by questioning about the timing and the occurrence of symptoms.
People who have had hay fever before will often consult the pharmacist
when symptoms are exacerbated in the summer months.

Danger symptoms/associated conditions
When associated symptoms such as tightness of the chest, wheezing,
shortness of breath or coughing are present, immediate referral is
advised. These symptoms may herald the onset of an asthmatic attack.

Wheezing
Difficulty with breathing, possibly with a cough, suggests an asthmatic
attack. Some sufferers only experience asthma attacks during
the hay fever season (seasonal asthma). These episodes can be quite
severe and require referral. Seasonal asthmatics often do not have
appropriate medication at hand as their attacks occur so infrequently,
which puts them at greater risk.

Earache and facial pain
As with colds and flu , allergic rhinitis can be complicated
by secondary bacterial infection in the middle ear (otitis media) or the
sinuses (sinusitis). Both these conditions cause persisting severe pain.

Purulent conjunctivitis
Irritated watery eyes are a common accompaniment to allergic rhinitis.
Occasionally this allergic conjunctivitis is complicated by a secondary
infection. When this occurs, the eyes become more painful
(gritty sensation) and redder, and the discharge changes from being
clear and watery to coloured and sticky (purulent). Referral is needed.

Medication
The pharmacist must establish whether any prescription or OTC
medicines are being taken by the patient. Potential interactions between
prescribed medication and antihistamines can therefore be
identified.

It would be useful to know if any medicines have been tried already
to treat the symptoms, especially where there is a previous history of
allergic rhinitis. In particular, the pharmacist should be aware of the
potentiation of drowsiness by some antihistamines combined with
other medicines. This can lead to increased danger in certain occupations
and driving.

Failed medication

 
If symptoms are not adequately controlled with OTC preparations, an
appointment with the doctor may be worthwhile. Such an appointment
is useful to explore the patient’s beliefs and preconceptions about
hay fever and its management. It is also an opportunity to suggest
ideas for the next season.

When to refer

• Wheezing and shortness of breath
• Tightness of chest
• Painful ear
• Painful sinuses
• Purulent conjunctivitis
• Failed medication