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Allergic rhinitis, also widely known as hay fever, affects up to 10-20% of people globally.1 An allergic response to triggers such as pollen or animal fur generally causes hay fever. Furthermore, it can result in symptoms such as a runny nose, itchy eyes, sneezing and nasal congestion.2-4 Quality of life can be severely affected by allergic rhinitis.2
Several medications, often in combination, can be used to treat hay fever symptoms. They typically include nasal corticosteroids, antihistamines, and decongestants.2,3

OVERVIEW: WHAT IS ALLERGIC RHINITIS?
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Allergic Rhinitis, or hay fever, is an inflammatory condition of the nasal lining. This is caused by an allergic reaction to airborne triggers, which can differ from person to person. Off course, the most common triggers include pollen, grass, pet fur and dust mites.2
Hay fever can occur during a specific season, in particular Spring, when pollen counts are high. This is termed seasonal allergic rhinitis. Conversely, when hay fever occurs throughout the year, we refer to it as perennial allergic rhinitis.3
When an allergen, that is to say, a trigger, enters the body, the body mounts an antibody response with IgE (immunoglobulin E). Therefore, people with allergies have higher levels of IgE.3 Mast cells; in other words, cells in the surface tissue, for instance, nasal mucosa, are key players in inflammatory responses. These cells release a number of substances, including histamine, IL-4, IL-13, TNF-α, leukotrienes and prostaglandins.5
Following this, these substances cause itching, swelling, and ‘leaking’ fluid from cells. This, in turn, leads to the symptoms of allergic rhinitis.

CAUSES AND RISK FACTORS
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There are multiple triggers of hay fever, which differ between people. What is more, some underlying conditions may further increase susceptibility to hay fever.
Common triggers
Hay fever triggers are often seasonal and include:2

  • Pollen from trees, flowers, and grasses, especially common in spring.
  • Dust mites.
  • Pet fur (may be worse in winter when houses are closed up).
  • Perfumes, smoke, and other air pollutants

Risk factors
Hay fever is thought to be genetic and can be worsened by frequent exposure to triggers.3,6 Moreover, several conditions can predispose people to allergic rhinitis and likewise cause it to be more severe. These include:2

  • Other allergic conditions, such as asthma*.
  • Atopic dermatitis (eczema).
  • A family history of allergy.
  • Living in an area with high exposure to triggers.
  • History of maternal smoking in the first year of life.

*Significantly, up to 80% of asthmatics also have allergies.7

 

Flowers producing pollen that leads to hay fever

SYMPTOMS OF ALLERGIC RHINITIS
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The initial symptoms of hay fever may be confused with those of a common cold. In contrast to a common cold, hay fever is not contagious and is not associated with fever. It is, however, characterised by the following: Firstly, a watery discharge from the nose. Secondly, it starts immediately after exposure to a trigger. And finally, it resolves when the trigger is removed. Furthermore, the common cold only starts 1-3 days after exposure to the virus and eventually resolves within 3-7 days.2,3

Common symptoms of hay fever include:1-4

  • Nasal congestion.
  • Sneezing and runny nose.
  • Cough.
  • Postnasal drip.
  • Itching of the nose, throat, and eyes.
  • Excessive tear production.
  • Sleep disturbances and difficulty waking.
  • Daytime sleepiness and dysfunction.

Further complications may include worsening asthma, sinusitis, and otitis media.2

BURDEN ON QUALITY OF LIFE
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Hay fever undoubtedly places a significant burden on quality of life. For example, a lack of sleep, constant itching, and a running nose can lead to irritability, work/school absences, and decreased productivity. In today’s fast-paced lifestyle, this is obviously far from ideal.2
The costs of hay fever can be significant.6For instance, direct costs such as doctor’s visits and medication, and of course, indirect costs like lost workdays and productivity.
When to see a doctor
You should seek medical attention if:2

  • Symptoms of allergic rhinitis are not relieved when using allergy medication.
  • You have other conditions which may worsen the condition. For example, asthma, sinusitis and/or nasal polyps.

DIAGNOSIS OF ALLERGIC RHINITIS
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Diagnosis of mild hay fever is usually made based on symptoms,3 although more severe hay fever may require allergy testing to establish triggers. Allergy testing is done by the skin prick and/or blood tests.2,3

Skin prick test

During the skin prick test, a small drop of each suspected allergen (trigger) is placed on the skin, and after that, the skin is scratched with a sterile needle. If the skin becomes red and/or swells, sensitisation to that allergen is confirmed, and indeed an allergy to that allergen is probable.3
Most importantly, the identification of triggers allows for their possible avoidance.

Allergy blood test

Several blood tests may also be performed to aid diagnosis of hay fever, for instance, IgE antibody testing.3

TREATMENT OF ALLERGIC RHINITIS
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There are multiple processes involved in hay fever. As a result, patients often need to be treated with a combination of medicines.2 Obviously, this can have a significant financial impact.6 The most used medication classes include antihistamines, nasal or oral corticosteroids, decongestants, and leukotriene modifiers.2

Antihistamines

Antihistamines block histamine, which can alleviate the itching, sneezing and runny nose.2 Most commonly, they are given orally. However, nasal sprays and eye drops are also available, which act locally.

Corticosteroids

Corticosteroids reduce inflammation and decrease the production of substances that cause an allergic response.3 For these reasons, they are often the first choice for treating allergic rhinitis.2

Decongestants

Decongestants can help to control symptoms such as inflammation. However, they cannot eradicate the cause of hay fever. They decrease swelling in the nose, allowing easier breathing. On the other hand, if used for too long (> 5 days), they can cause rebound congestion when one stops using them.3

Leukotriene modifiers

Leukotriene modifiers act on leukotrienes, which form part of the allergic response. They are generally not used as first-line treatment.3

Combination treatment

Intranasal combinations of antihistamine and corticosteroids are available. These combinations reduce the need for polypharmacy while at the same time treating hay fever using dual mechanisms with both short-acting and long-acting effects.8

 

  • A combination nasal spray has been developed to meet the demand for improved symptom control.
  • The first combination of an INCS and IAH in South Africa, thus eliminating the need for polypharmacy.
  • Rapid onset of action, within 10 – 15 minutes.
  • Provides both nasal and ocular symptom relief.
  • Sustained symptom and QOL improvement from day 1.

PREVENTION AND LIFESTYLE CHANGES
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Although complete avoidance of hay fever triggers is not always possible, it can minimise the risk and severity of hay fever. 2
In many people, long-term treatment prescribed by a doctor (often only during ‘allergy season’, i.e., before exposure to allergens) can minimise symptoms and consequently the burden on quality of life.

For more information, speak to your healthcare professional!


1. Liu, J., Zhang, X., Zhao, Y., et al.

The association between allergic rhinitis and sleep: A systematic review and meta-analysis of observational studies. PLoS ONE 15(2): e0228533. Available at: https://pubmed.ncbi.nlm.nih.gov/32053609/. Accessed 2021 July 30.

2. Mayo Clinic. Allergic rhinitis. Updated 2020 July 6.

Available at: https://www.mayoclinic.org/diseases-conditions/hay-fever/symptoms-causes/syc-20373039. Accessed: 2021 July 30.

3. Allergic rhinitis. Updated 2021 January 29.

Available at: https://www.medicinenet.com/hay_fever/article.htm#is_allergic_rhinitis_contagious. Accessed 2021 July 30.

4. Green, R.J., Hockman, M., Friedman, R., et al. (on behalf of the South African Allergic Rhinitis Working Group (SAARWG)).

Allergic Rhinitis in South Africa: 2012 Guidelines. S Afr Med J 2012;102(8). Available at: file:///C:/Users/01361002/Desktop/210731_Allergic%20rhinitis_SA%20Guideline_2012.pdf. Accessed 2021 July 31.

5. Weller, C. (British Society for Immunology). Mast cells.

Available at: https://www.immunology.org/public-information/bitesized-immunology/cells/mast-cells. Accessed 2021 July 31.

6.Tran, N.P., Vickery, J. Blaiss, M.S.

Management of Rhinitis: Allergic and Non-Allergic. Allergy Asthma Immunol Res. 2011 July;3(3):148-156. doi: 10.4168/aair.2011.3.3.148

7. Asthma Australia. Asthma and allergies.

Available at: https://asthma.org.au/about-asthma/live-with-asthma/asthma-and-allergies/. Accessed 2021 July 31.

8. Gross GN, Berman G, Amar NJ, et al.

Efficacy and safety of olopatadine-mometasone combination nasal spray for the treatment of seasonal allergic rhinitis. Ann Allergy Asthma Immunol, 2019;122:630-638.

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