Hay fever/Seasonal Allergic Rhinitis and Conjunctivitis
(adults)
Key Messages
Diagnosis and management of seasonal (spring/summer) allergic
rhinitis/conjunctivitis. For seasonal allergic rhinitis see separate guidelines.
Assessment
Bilateral nasal itching, congestion and rhinorrhoea, sneezing, or bilateral
conjunctivitis.
Differential diagnosis
- Perennial rhinoconjunctivitis (non-seasonal)
- Infective rhinosinusitis
- Non-allergic (eg hormonal, drug-induced, vasomotor) rhinitis
For diagnostic algorithm see
http://www.bsaci.org/Guidelines/Algorithm-RhinitisPCGL.pdf
Red Flags
Unilateral symptoms, polyps, persistent blood stained discharge or persistent
purulent discharge – consider referral to ENT.
Investigations
No investigations recommended prior to referral.
Management
1. Mild symptoms should be treated with oral non-sedating antihistamines at
doses up to twice BNF maximum dosing (cetirizine 10mg, loratadine 10mg, or
fexofenadine 180mg up to twice daily).
2. Moderate-severe symptoms should be treated with intranasal corticosteroid
(eg Beconase, two sprays into each nostril twice daily; consider trying
alternative, eg Nasonex or Avamys) 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. Start antihistamines and intranasal corticosteroids two weeks
before usual symptom onset and continue throughout season
b. Training in appropriate nasal spray technique essential. Guidance is
available at
http://www.nationalasthma.org.au/uploads/publication/intranasalcorticosteroid-spray-technique.pdf
Version: 3
Date last edited: 10/06/15
Locality: Devon wide
Amendments by: Kevin Bishop
3. Systemic corticosteroids (in addition to intranasal corticosteroid) at doses of
15-20mg for a maximum of 5 days as a one-off treatment can be used for
severe symptoms uncontrolled on conventional therapy, to control symptoms
during important periods (eg exams or other major events).
4. Topical cromoglicate and nedocromil eyedrops are useful to manage allergic
conjunctivitis.
Consider a concomitant diagnosis of asthma and manage according to guidelines
- Montelukast can be added to conventional therapy in patients with seasonal
allergic rhinitis and concomitant asthma.
Avoid sedating
decongestants.
antihistamines,
depot
corticosteroids,
and
chronic
use
of
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.
Experience from Peninsula Immunology and Allergy Service suggests that 70% of
patients referred with severe symptoms achieve satisfactory symptom control using
non-sedating antihistamines and regular intranasal corticosteroids alone.
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
Referral
Referral criteria
i)



Seasonal symptoms that are severe and resistant to treatment (when
combination treatment at maximum doses has been attempted throughout
the season). Treatment should be initiated at least 2 weeks before the
anticipated start of the pollen season.
Referral Instructions
Red Flags – refer to ENT
Refer via DRSS for NEW Devon CCG patients
Choose and Book Selection
Specialty: ENT
Clinic type: Not otherwise specified
Service: DRSS- Western – ENT -NEW Devon CCG - 99p
Version: 3
Date last edited: 10/06/15
Locality: Devon wide
Amendments by: Kevin Bishop



Refer to Peninsula Immunology and Allergy Service
Choose and Book Selection
Specialty: Allergy
Clinic type: Allergy
Service: DRSS- Western –Allergy & Immunology - CCG - 99p
Referral Forms
DRSS Referral form
Supporting Information
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
This guideline has been signed off by the Western Locality on behalf of NEW Devon
CCG.
Publication date: June 2015
Review date: May 2017
Version: 3
Date last edited: 10/06/15
Locality: Devon wide
Amendments by: Kevin Bishop