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Hay fever treatment – the essential skills. Samantha Walker PhD Director of Research, National Respiratory Training Centre, Warwick |
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Hay fever (or seasonal allergic rhinoconjunctivitis) is estimated to affect
15-23% of children (Sibbald, B. et al. 1990), with a peak age of onset in adolescence (Burr, M.L. et al.1989, and Frossard,
N. et al. 1998). Common
symptoms include sneezing, itching, watery rhinorrhoea and nasal blockage,
which are not only irritating and distracting but can also limit activity,
cause practical and emotional problems and disturb sleep (Juniper, E.F.
et al. 1990). Chronic symptoms may lead in turn to poor concentration,
impaired learning ability and school absenteeism. It is therefore important
to identify teenagers or young adults with persistent or severe hay
fever, and to treat their symptoms early and aggressively to prevent
avoidable poor performance at school or work. Hay fever and effects on learning Most studies investigating the effects of allergic rhinitis on learning
ability have used realistic computer simulation of the classroom situation
to assess factual and conceptual knowledge and learning strategy. One
such open study, in children aged 10–12 years, identified consistent
and significant learning impairment in those children with symptomatic
allergic rhinitis compared to non-allergic controls (Vuurman, E.P.F.
et al. 1993). These findings were confirmed in a double-blind placebo-controlled
trial in adolescents (15–25 years), which compared the effects on learning
ability of diphenhydramine hydrochloride (a first-generation sedating
antihistamine), a compound of acrivastine (Second-generation non-sedating
antihistamine) and pseudoephedrine (decongestant), and placebo. Subjects
with allergic rhinitis treated with placebo performed significantly
less well than non-allergic controls in all tests of learning ability,
while those treated with diphenhydramine experienced further impairment
of learning (Vuurman, E.P.F. et al. 1993). Treatment for hay fever Strategies for managing hay fever include minimising exposure to individual triggers
and use of appropriate preventive and therapeutic medication. Avoiding pollens Avoiding airborne pollens is difficult, but patients can help themselves
by sleeping with windows closed, staying indoors when pollen levels
are highest (early morning and late afternoon/early evening), and keeping
car windows closed. Pollen forecasts vary daily, influenced mainly by
the weather. Forecasts are published in daily newspapers from the end
of May and on Ceefax and Teletext; they can also be accessed via the
Internet at, sites such as, www.bbc.co.uk/weather and www.pollen.co.uk. Drug treatment When exams are looming it is particularly helpful to start preventive treatment
for hay fever before pollen counts peak – modern hay fever treatments
are extremely effective if taken prophylactically. Base drug treatment
on the presence/absence of individual symptoms and follow evidence-based
guidelines (Bousquet, J. et al. 2001, and Walker, S.M. et al. 2002). Mild, intermittent symptoms usually respond to non-sedating antihistamine
such as cetirizine (Zirtek), lecocetirizine (Xyzal), fexofenadine (Telfast)
or desloratidine (Neoclarityn). Avoid sedating anti-histamines as these
may further impair concentration and learning ability in hay fever sufferers
(Vuurman, E.P.F. et al. 1993). Topical nasal steroids are the first-line treatment for persistent moderate
or severe symptoms (Weiner, J.M. et al. 1998), with non-sedating anti-histamine added as required. When prescribing topical
nasal steroids, always explain how to use the spray otherwise treatment
is likely to fail. Sniffing on application, for example, tends to deliver
the drug to the stomach rather than the nose. Instructions for use (preferably
written, and available from www.nrtc.org.uk) should accompany any nasal
spray prescription. Patients should be followed up two weeks after the
onset of symptoms to review the effectiveness of prescribed treatment. Summer hay fever affects about a quarter of adolescents and young adults,
most of whom are required to sit important exams during the peak of
the grass pollen season. Identifying sufferers before the onset of high
pollen counts and starting regular treatment early will allow effective
symptom control and may prevent the development of more severe symptoms.
Treatment failure may be related to poor compliance, perhaps because
of the sedating effects of antihistamines, or to poor nasal spray technique.
If treatment fails, or as an emergency treatment before exams or an
important event, a short course of oral steroids – for example, prednisolone
20 mg daily for five days – is effective. Depot steroid injections have
no place in hay fever management because of side effects (DrugTherBull
37:17-8, 1999) and are unnecessary if a structured treatment approach
is used. References 1. Sibbald B, Rink E, D’Souza M. Is the prevalence
of atopy increasing? Br J Gen Pract 1990;40:338-40. 2. Burr ML, Butland BK, King S, Vaughan-Williams
E. Changes in asthma prevalence: two surveys 15 years apart. Arch
Dis Child 1989;64:1452-6. 3. Frossard N, Melac M, Benabdesselam O, Pauli
G. Consistency of the reactivity of cetirizine and ebastine on skin
reactivity. Ann Allergy Asthma Immunol 1998;80:61-5. 4. Juniper EF, Guyatt GH. Development and
testing of a new measure of health status for clinical trials in rhinoconjunctivitis.
Clin Exp Allergy 1990;21:77-83. 5. Vuurman EPF, van Veggel LMA, Uiterwijk
MMC, Leutner D, O’Hanlon JF. Seasonal allergic rhinitis and anti-histamine
effects on children’s learning. Ann Allergy 1993;71:121-6. 6. Bousquet J, Van Cauwenberge P, Khaltaev
N. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol
2001;108(5):s147-s333. 7. Walker SM, Sheikh AS. 10-minute consultation:
Rhinitis. BMJ 2002;324:403. 8. Weiner JM, Abramson MJ, Puy RM. Intranasal
corticosteroids versus oral H1-receptor antagonists in allergic rhinitis:
systemic review of randomised controlled trials. BMJ 1998;317:1624-9. 9. Any place for depot triamcinolone in hay
fever? Drug Ther Bull 1999;37:17-8. c l i n i c a l u p d a t e INGRAM |
