Cobra Allergic Rhinitis Management Clinical Algorithm Guide (EN)

Management of Allergic Rhinitis in Primary Care ( Step 3 Additional medication depending on predominant symptoms Watery rhinorrhea Add intranasal ipratropium bromide Itch/sneeze Add regular use non-sedating anti-histamine Catarrh Add LTRA montelukast if asthmatic Blockage Add short term decongestant eg. Pseudoephedrine- briefly or oral corticosteroid or long acting non-sedating topical azelastine/LTRA Step 4 ENT referral If Infection/ structural problem If persistent blockage/ check for nasal polyps- treat polyps with steroid nasal drops. Nasal drops must be administered correctly (whilst patient laying on bed on back with head hanging over edge of bed. Refer to ENT if polyps persist.

OR Consider referral for immunotherapy if symptoms predominantly due to one allergen Date Approved: January 2021 (APC 13 th January 2021, minor amendment 12 th October 2021) Review Date:

January 2023 1 Step 1- Patient to see their local pharmacist • Advice on Allergen Avoidance (see Appendix 1) • Advice on nasal douching/irrigation (see Appendix 2) • If mild symptoms, recommend OTC antihistamines – Table 1 • If moderate /persistent symptoms recommend OTC nasal steroids -Table 2 • If referring to purchase OTC from pharmacy please refer to Barnsley Self-Care Guidance for general and OTC exceptions Oral antihistamine Table 1 Nasal antihistamine Eg azelastine Nasal steroids Table 2 Nasal decongestant Eg.

Pseudoephedri- ne Ipratropium bromide Nasal chromone Rhinorrhoea ++ ++ +++ - ++ + Sneezing ++ ++ +++ - - + Step 2 - Patient to see GP • Check nasal steroid technique • Allergen avoidance - Appendix 1 • +/ - Nasal irrigation - Appendix 2 • Increase dose of nasal steroid/ or consider short course of oral corticosteroid.

(Recommended intranasal steroids Beclometasone, Budesonide, Fluticasone furoate) see Table 2 • Consider specific allergen test – specific IgE RAST OR referral for Skin Prick Test -if specific allergen causing symptoms unknown and symptoms persistent refer to Sheffield Allergy/Immunology clinic Paediatrics to Paediatric immunology clinic BHNFT Itching ++ ++ +++ - - + Blockage + + +++ +++ - + Eye symptoms ++ - ++ - - - Onset of action 1h 15 min 12h 5-15 min 15-30 min variable Duration 12-24h 6-12 h 12-48h 3-6 h 4-12 h 2-6 h

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Table 1. Comparison of non-sedating antihistamines on the Barnsley formulary – For products available OTC always signpost to pharmacy unless restriction criteria in Barnsley Self-Care Guidance is satisfied. in order of expense for each generation (least expensive first), from Drug Tariff August 2020. *Denotes first line options Date Approved: January 2021 (APC 13 th January 2021, minor amendment 12 th October 2021) Review Date:

January 2023 2 Antihistamine % Sedation/ somnolence or CNS impairment (control) Dose Prescription Cost for 28 days (£) Age limit in years (SAR=Seasonal Allergic Rhinitis) Cetirizine (10mg tabs)* Available Over The Counter, see Barnsley Self Care Guidance 14 (10) 10mg od 0.94 6 years Loratadine (10mg tabs)* Available Over The Counter, see Barnsley Self Care Guidance 8 (6) 10mg od 0.98 2 years (body weight over 30kg) Fexofenadine (120mg tabs) 1.3 (0.9) 120mg od 2.14 12 years Cetirizine oral solution (5mg/5ml) Available Over The Counter, see Barnsley Self Care Guidance 14 (10) 10mg od (2-5yr = 5mg daily) 2.17 (1.09) 6 years 2 years SAR only Azelastine 0.1% (intranasal) Prescription Only 11.5 (5.4) 1 spray both nostrils bd 3.77 6 years Fexofenadine (30mg tabs) Prescription Only 1.3 (0.9) 30mg bd 5.10 6-11 years Loratadine syrup (5mg/5ml) Available Over The Counter, see Barnsley Self Care Guidance 8 (6) 10mg od over 30kg (5mg od under 30kg) 5.90 (2.95) 2 years

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Table 2. Intranasal corticosteroid sprays on Barnsley formulary - For products available OTC always signpost to pharmacy unless restriction criteria in Barnsley Self-Care Guidance is satisfied. in order of expense (least expensive first), from Drug Tariff August 2020. ** Pregnancy risk category: B Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women. C Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. Date Approved:

January 2021 (APC 13 th January 2021, minor amendment 12 th October 2021) Review Date: January 2023 3 Intranasal steroid spray (INS) Prescribe as the pack size listed below to ensure most cost-effective product prescribed. Starting dose Maintenance dose 28 day prescription cost (maintenance dose) £ Licensed Age limit in years Pregnancy risk category** Beclometasone (generic) 50µg/dose, 200 doses. Available Over The Counter for Adults only, see Barnsley Self Care Guidance 2 sprays into each nostril BD 1 spray into each nostril BD 1.70 6 (18 Over the counter) C Budesonide (prescribe as the cost-effective brand Rhinocort Aqua®) 64µg/dose, 120 doses.

Available Over The Counter for adults only, see Barnsley Self Care Guidance 2 sprays into each nostril OD or 1 spray into each nostril BD 1 spray into each nostril OD 2.63 12 (18 Over the counter) B Mometasone furoate 50µg/dose, 140 doses. Available Over The Counter for adults only, see Barnsley Self Care Guidance 2 sprays into each nostril OD 1 spray into each nostril OD 2.68 3 (18 Over the counter) C Fluticasone propionate 50µg/dose, 150 doses. Available Over The Counter for adults only, see Barnsley Self Care Guidance 2 sprays into each nostril OD 1 spray into each nostril OD 2.98 4 (18 Over the counter) C Fluticasone furoate (Avamys®) 27.5µg/dose, 120 doses.

2 sprays into each nostril OD 1 spray into each nostril OD 3.22 6 C

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Appendix 1: Avoidance strategies for common rhinitis-causing allergens Date Approved: January 2021 (APC 13 th January 2021, minor amendment 12 th October 2021) Review Date: January 2023 4 Allergen Type Allergen Exposure Period Allergen Avoidance Strategies Pollen* Early tree pollen e.g. alder, hazel Seasonal (Jan- March). Intermittent or chronic symptoms. • Check pollen count (highest in the morning and evening and when humid or windy). Stay indoors when high. • Avoid grassy open spaces (parks, fields, and activities such as cutting grass); change clothes and shower after going out; keep pets out of the house during the hay fever season and wash them regularly; wear wrap-around sunglasses.

Plan holidays to avoid the pollen season. • Avoid fresh flowers in the house; keep car and house windows closed (especially during mid- morning and early evening); consider buying a pollen filter for the air vents in your car and changing these with each service. • Vacuum (ideally with a HEPA filter) and damp dust regularly. • Avoid exposure to smoke which irritates the lining of your nose, eyes, throat and airways and makes symptoms worse. Mid/late tree pollen e.g. silver birch Seasonal (March- April). Grasses Seasonal (May-July). Intermittent or chronic symptoms. Nettles and other weeds Seasonal (July- Sept). Intermittent or chronic symptoms. Fungi (moulds) Persistent or intermittent.

Ubiquitous allergen-producing fungi can grow on any decaying matter, both inside and outside the house. Allergenic mould spores are released when there is a sudden rise in temperature in a moist environment e.g. when central heating is turned on in a damp house, or someone dries wet clothes next to a fireplace. • Indoor mould is influenced by the age and construction of the building, type of heating system, and use of humidifiers and air conditioning. • Eliminate sources of moisture, such as water intrusion, cold surfaces, and elevated humidity, keep home dry, well ventilated and do not dry clothes indoors, or store clothes in damp cupboards.

• Dehumidifiers can help reduce damp and resultant mould levels in the house. • Indoor mould can be controlled somewhat via chemical and physical measures such as fungicides, careful cleaning of humidifiers and vaporisers. The overall effectiveness of these measures, however, is dependent upon reducing relative humidity by removing all sources of moisture and condensation levels. • Scour sinks and tubs at least once a month.

• Use dilute bleach on nonporous surfaces, whereas porous surfaces must be removed and/or replaced • Avoid outdoor moulds by remaining indoors and using air conditioning on an indoor cycle; however, it is important to note that air conditioning units themselves may be heavily contaminated with mould and these may need to be cleaned or replaced. • When involved in plant-disturbing activity, such as gardening and lawn mowing, facemasks can reduce exposure to fungi. House dust mites (HDM) Perennial. • Persistent symptoms usually present throughout the year (although HDM numbers tend to peak in spring and autumn), requiring ongoing treatment. Usually worse on waking.

•Single HDM avoidance measures are not routinely recommended because they are inconvenient, difficult to achieve, require long-term commitment, expensive and lack of good quality evidence for their effectiveness. However, for confirmed HDM allergy inadequately controlled by drug treatment in people who want to try HDM avoidance measures, a number of experts have recommended a combination of the following measures:

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