The Allergy Foundation of South Africa (AFSA), is a registered Non-Profit Company, striving to save and enhance the quality of lives of patients suffering from allergies and immunodeficiencies. The foundation was established to create awareness and educate patients and to promote responsible allergy care through various initiatives. The online Allergy Masterclasses is an educational initiative, especially aimed at doctors, pharmacists, dieticians, and nurses to provide up-to-date training on allergy and immunodeficiencies. This year’s first Masterclass (one of eight planned for 2023) kicked off on Saturday, 18 March, with the theme “Rhinitis”! A panel of excellent presenters discussed this topic in detail, with Allergic rhinitis (also known as hay fever), being the focus of attention. We would like to share with our readers, information on this condition highlighted by our panel of experts during their presentations.
Allergic rhinitis is an extremely common condition, affecting up to 40% of the population. Allergic rhinitis can occur at any age. Although it is common in older children, adolescents and adults; children from as young as two years may also suffer from this chronic disease.
Untreated allergic rhinitis may have serious consequences and may significantly impair a patient’s quality of life. During the Masterclass, one of the panels of experts highlighted sleep disturbance as a common consequence. Patients with nasal obstruction do not sleep well and often wake up in the morning feeling tired and unrested; with an impairment in work performance, concentration, and emotional well-being, important repercussions. School performance may also be affected and children may be incorrectly diagnosed with learning disabilities and even attention deficit disorder (ADD) as a result. Recurrent otitis media, atopic dermatitis, chronic rhinosinusitis, and asthma are frequent co-morbid conditions associated with allergic rhinitis. Allergic conjunctivitis frequently occurs with allergic rhinitis – a condition known as allergic rhinoconjunctivitis.
The diagnosis of allergic rhinitis is made only after a good medical history is taken, followed by an adequate physical examination. This includes a meticulous examination of the nose, ears and throat and eyes. Skin prick testing is considered the gold standard for identifying allergens. Alternatively, blood can be drawn to measure antibodies against specific allergens based on the patient’s clinical history. These tests indicate sensitisation and not necessarily a true allergy. The results should therefore be interpreted with caution and clinicians should decide which allergen sensitisations (positive results) are relevant to the patient’s nasal and eye symptoms.
Four integrated pillars, all implemented simultaneously, should form part of effective allergic rhinitis treatment:
- Patient Education
- Adequate and practical patient allergen and trigger avoidance strategies
- Pharmacotherapy (medication)
- Allergen immunotherapy
Ten common flaws and pitfalls in the management of allergic rhinitis, have been identified during the Masterclass:
1. Patients are not properly educated about their allergic rhinitis.
- Allergic rhinitis is a chronic, inflammatory condition, requiring medicine (anti-inflammatories) to be taken every day.
2. Patients do not realise that corticosteroid nasal sprays are the most effective treatment for allergic rhinitis
- Intranasal corticosteroid nasal sprays are the only effective anti-inflammatory treatment available to treat the symptoms of allergic rhinitis. These should be taken daily, to prevent, rather than treat nasal symptom “flare-ups”.
3. The therapeutic effectiveness of nasal rinses and washouts is being underestimated.
- Nasal rinses and washouts should be taken before intranasal corticosteroids, allowing the latter to penetrate better into the nasal tissue and wash allergens off the nasal mucosa.
4. Patients do not know how to use their nasal sprays and nasal rinses.
- The utmost care should be taken to ensure the correct technique is used when using nasal sprays and washouts, otherwise, these medicines will be ineffective and cause unwanted side effects (eg nasal bleeding).
5. Patients are often scared to use nasal steroids, because of “steroid phobia”.
- Newer generation intranasal steroids sprays are safe, even during long-term use. They are delivered topically and designed to stay within the nasal mucosa with very little to no of drug being absorbed in the bloodstream.
6. Allergen avoidance strategies are being implemented incorrectly.
- Clinicians should avoid advocating for “blanket” allergen avoidance strategies. These are often time-consuming and expensive for patients to implement. Strategies should therefore be carefully tailored, based on each patient’s individual symptom history and interpretation of allergy test results.
Patients should be encouraged to practice relevant avoidance strategies continuously and throughout the simultaneous use of their allergic rhinitis medicine.
7. Patients overuse (abuse) nasal decongestants and intramuscular antihistamines.
- Nasal decongestant sprays and intramuscular “rescue” injections should be avoided, due to severe rebound nasal symptoms occurring when these medicines start to wear off.
Nasal decongestants are readily available as over-the-counter medications and patients are often receiving these in an uncontrolled manner. These lead to decongestant abuse and eventually, nasal dependence. Short courses (less than 5 days) may be used during severe symptom “flare-ups”.
8. Over-the-counter, older-generation antihistamines are often prescribed for viral colds in an uncontrolled manner.
- Smaller children are often incorrectly diagnosed as having recurrent viral upper airway infections, when in fact, they suffer from allergic rhinitis. For the newer generation, safe and non-sedating antihistamines should be prescribed, and for older generations, sedating antihistamines should be avoided due to unwanted side effects.
9. Medical practitioners may fail to recognize the need for referral to a specialist.
- Uncontrolled nasal symptoms, despite the correct, regular use of intranasal steroids and adequate allergen avoidance strategies, may indicate a non-allergic cause of nasal symptoms, especially when a nasal obstruction is present. Referral to a specialist, possibly an Ear Nose and Throat specialist (ENT), may be warranted in these patients.
10. Rotating through different antihistamines because of possibly developing “tolerance”, should be avoided.
- There is no scientific evidence for becoming tolerant to newer generation antihistamines. Switching every so often between antihistamines when symptoms become or remain uncontrolled, should be avoided and an intranasal corticosteroid spray should be used instead.
Patients should realise that, apart from immunotherapy, no curative treatment for allergic rhinitis exists. Therefore, our Masterclass ended with a discussion on aeroallergen immunotherapy. Clinicians are encouraged to consider early patient referral to an allergist, for this highly effective, disease-modifying treatment.
For more up-to-date information on allergic rhinitis and other allergic and immunodeficiency conditions, our readers are once more encouraged to visit our website at https://allergyfoundation-old.local. We look forward to our next Allergy Masterclass in May this year. This time the focus will be on asthma – the most common chronic lung condition in children!