Seasonal Allergic Rhinitis and Conjunctivitis (Adult) Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • Diagnosis and management of seasonal (spring/summer) allergic rhinitis/conjunctivitis
  • Adults 18+

This guidance does not cover

Assessment

Signs and Symptoms

  • Bilateral nasal itching
  • Congestion and rhinorrhoea
  • Sneezing
  • Bilateral conjunctivitis.

Differential Diagnosis

  • Perennial rhinoconjunctivitis (non-seasonal)
  • Infective rhinosinusitis
  • Non-allergic (e.g. hormonal, drug-induced, vasomotor) rhinitis

For diagnostic algorithm see - BSACI – Guidelines/Algorithm-RhinitisPCCL

Red Flags

Seek immediate or urgent specialist advice/treatment if:

  • Unilateral symptoms
  • Polyps
  • Persistent blood stained or purulent discharge or persistent purulent discharge

Management

Allergen Avoidance
  • Management should start with allergen avoidance by advising patient to:
    • wear wraparound sunglasses to stop pollen getting in your eyes when you're outdoors
    • take a shower and changing your clothes after being outdoors to remove the pollen on your body
    • stay indoors when the pollen count is high (over 50 grains per cubic metre of air)
    • apply a small amount of Vaseline (petroleum gel) to the nasal openings to trap pollen grains
Mild symptoms
  • Should be treated with oral non-sedating antihistamines at doses up to twice BNF maximum dosing (cetirizine 10mg, loratadine 10mg, up to twice daily).
  • A self-care approach should be adopted and the patient should be encouraged to purchase their antihistamines cheaply from the supermarket or other outlets
Moderate-severe symptoms
  • Should be treated with intranasal corticosteroid (e.g. beclometasone, two sprays into each nostril twice daily; consider trying alternative (e.g. mometasone 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. - Again a self-care approach is advised as this product can be bought cheaply over the counter
  • Start antihistamines and intranasal corticosteroids two weeks before usual symptom onset and continue throughout season
  • 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 (e.g. exams or other major events).
  • Topical sodium cromoglicate eye drops 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 antihistamines, depot corticosteroids, and chronic use of decongestants.

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.


Referral

Referral Criteria

  • Red Flags
  • 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

  • e-Consultation is not currently available for this speciality
  • Red Flags should be referred to ENT
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals routine referrals should be made to The Allergy Clinic (LTHT) via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation

Patient information/Public Health/Self Care

Evidence/additional information

Assurance & Governance

  • This guidance was developed on: 10.2017
  • This Care Pathway was ratified by: The OSCAR Assurance Group
  • Date ratified: 10.2017
  • Publication Date: 12.2017
  • Review Date: 10.2019
  • Ref No: AL7 - 03.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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