After reading this feature you should be able to explain:
• The treatment options for the symptoms of allergic conjunctivitis associated with hayfever
• How to differentiate between a common cold and hayfever
• The importance of good baseline disease control in asthma patients who also suffer from hayfever.
Hayfever affects people in different ways and, depending on their circumstances, the advice pharmacists offer needs to be different too. Here, we consider a number of case histories where your response could make all the difference to sufferers.
Karen Hilton, a 27-year-old school teacher, is pregnant with her first child. She is a regular customer at the pharmacy during the spring and summer months for OTC hayfever medication. With the pollen season fast approaching, Karen wants to know how to manage her hayfever symptoms during pregnancy. She is also concerned that having hayfever will increase the likelihood of her child developing the same allergy and wants to know how this risk can be reduced.
Hayfever often proves particularly problematic during pregnancy, as underlying hormonal changes can exacerbate the symptoms of nasal congestion. According to the UK Teratology Information Service (UKTIS), the first step in managing hayfever in pregnancy should be to avoid or limit pollen exposure.1 Simple lifestyle tips that can help Karen minimise pollen exposure and reduce her allergic symptoms include:
• Keeping windows shut at night and first thing in the morning
• Remaining indoors when possible if the pollen count is high (between 50 and 150)
• Wearing wraparound sunglasses to protect the eyes
• Applying petroleum jelly or another nasal blocker just inside the nostrils to trap pollen before it can enter the airways
• Not mowing the lawn or sitting/standing in grassy areas
• Washing hands and face regularly, particularly when getting home
• Avoiding exposure to other allergens, such as pet fur or environmental irritants like insect sprays or tobacco smoke.
If lifestyle changes prove insufficient, treatment options that can be considered during pregnancy include corticosteroid nasal sprays, sodium cromoglicate nasal sprays or antihistamine/cromoglicate eye drops, if thought essential by a doctor.2
According to UKTIS, “the antihistamine or corticosteroid in eye drops and nasal sprays enters the bloodstream in very small amounts. The dose of medicine that reaches the baby in the womb is therefore very small and would not be expected to affect an unborn baby”.1
Sprays or eye drops containing decongestants should ideally be avoided during pregnancy. Of the oral antihistamines, loratadine is generally the preferred first choice for use during pregnancy due to the amount of supportive safety data, with cetirizine and chlorphenamine as alternatives.2 However, these drugs as a class are often precluded from OTC use in pregnancy due to the manufacturers’ licensing restrictions.
If Karen feels strongly that an oral antihistamine is needed, suggest she consults her GP for further advice.
There is no clear way to predict whether Karen’s unborn child will also suffer from hayfever, although the risk is undoubtedly higher than it would be for a non-hayfever sufferer.
Over 50 per cent of children born into a family with allergies will go on to develop an allergic disease themselves (compared to one in five in the general population) and the mother’s allergy history appears to have the greatest influence.3 This may result in the child developing hayfever or an alternative allergic condition such as eczema or asthma. What is inherited, and therefore appears to be genetic, is the tendency to develop allergies rather than the specific allergy itself.
Environmental factors can also have a significant impact on the development of allergies in children. Karen should be encouraged to avoid smoking and smoke exposure during her pregnancy as this is linked to a higher rate of allergy in offspring and more severe symptoms in those children who do develop allergies.
Eating a healthy balanced diet during pregnancy is also important. Although there is some evidence that vitamin E, fish oils and fresh fruit, particularly apples, can have an allergy prevention effect when consumed during pregnancy, the data is by no means conclusive.
Remind Karen that oily fish intake during pregnancy should be limited to two portions per week and supplements containing vitamin A should be avoided as excess is potentially harmful to the developing foetus.
Vaz Khan is a lorry driver who suffers from a severe allergy to grass pollen. As his symptoms mainly affect the eyes, leading to itching, redness and watering, Vaz is particularly concerned that hayfever may affect his ability to drive. He has come to the pharmacy before he sets out on a four-day long-haul drive into central Europe, looking for treatment advice.
Vaz is suffering from allergic conjunctivitis caused by his immune system overreacting to antigens in grass pollen, which leads to the characteristic symptoms of red, watery, itchy and gritty-feeling eyes. Grass pollen allergies tend to peak in early summer in the UK, usually lasting from April through to July. You can reassure Vaz that his ocular hayfever symptoms should not affect his vision or make his eyes more sensitive to light.4
In order to minimise symptoms, the following general measures can be recommended:
• Not wearing contact lenses until symptoms have subsided and/or while eye drops are being used
• Avoiding rubbing his eyes as this can exacerbate the inflammatory effect
• Bathing the eyes either with a flannel soaked in cold water or by using an OTC eye bath
• Minimising contact with the causative pollen. In Vaz’s case, key advice would include wearing wraparound sunglasses while driving, keeping the windows of his lorry shut and using internal air circulation. In most modern vehicles, this will include an inbuilt pollen filter.
To ease irritation, itching and redness, Vaz can try eye drops containing an antihistamine (e.g. azelastine) or a mast cell stabiliser (e.g. sodium cromoglicate), which will help dampen down his body’s allergic response to pollen. Both are relatively well tolerated but as azelastine only needs to be administered twice daily (compared to four times daily for sodium cromoglicate) this may be more convenient for Vaz when out on the road.
Another OTC eye drop contains a combination of the antihistamine antazoline with the vasoconstrictor xylometazoline, which acts to narrow tiny blood vessels in the surface of the eye and stop allergic mediators being transported to the site of irritation. Combination anti-allergy eye drops are not suitable for customers with narrow angle glaucoma or patients on monoamine oxidase inhibitors (or within 14 days of stopping such treatment).
Oral antihistamines tend to be less effective against ocular hayfever symptoms when the eyes are very irritated, as in Vaz’s case, and may occasionally cause drowsiness, which presents a potential safety issue when driving.4 If Vaz’s symptoms fail to resolve after all suitable OTC approaches have been exhausted, suggest he visits his GP as steroid-based drops may be an option, but these must be administered under close medical supervision due to the increased risk of eye infection.
Morgana Spence visits the pharmacy in early April complaining of a blocked nose and persistent sneezing. She also has a headache and feels unusually tired. Morgana recalls experiencing similar symptoms around the same time last year, which has led her to wonder if the cause could potentially be hayfever rather than a cold as she first suspected.
Although hayfever most commonly manifests during childhood or teenage years, onset can be at any age. Recent media reports suggest that an increasing number of UK adults in their 30s to 50s are developing hayfever, with half a million new middle-aged-onset cases expected over the course of the next decade.5 The reason for this rise is unclear but, as with the increasing incidence of so many other allergic conditions, is often attributable to the so-called ‘hygiene hypothesis’.
For Morgana, a correct diagnosis is important to allow optimal treatment of her underlying condition. For example, long-term use of OTC decongestants for a persistent cold could inflame the nasal lining and exacerbate symptoms of hayfever. Equally, corticosteroid or antihistamine nasal sprays will be ineffective against the non-allergic symptoms of a cold. The following diagnostic pointers can help distinguish one condition from the other:
• Colds are less likely to coincide with the pollen season and are more common during the colder winter months
• Colds are infectious. If anyone else in Morgana’s family is suffering with similar symptoms and is not known to have hayfever, then the chances are the cause is a viral infection
• Colds are generally self-limiting and will resolve within one to two weeks, whereas hayfever will persist (albeit at varying levels of intensity depending on the daily pollen count) for the duration of the allergic pollen season
• Hayfever does not usually cause coughing
• Throat manifestations of hayfever tend to be an itchy/tickly sensation rather than pain, whereas sore throats are a key symptom of a cold
• Hayfever symptoms tend to subside when indoors with the doors and windows closed, although residual nasal congestion may then develop.
You could suggest that Morgana tries keeping a diary of her symptoms and compares it with the local pollen forecast to look for any correlation. Another option would be to try an OTC hayfever remedy for a short period to see if it has any impact on her symptoms.
Other potential conditions which may explain Morgana’s symptoms include perennial allergic rhinitis or even non-allergic rhinitis. If the diagnosis remains unclear and symptoms do not resolve, suggest Morgana consults her GP for further advice and potential referral for skin prick allergy testing.
Todd Mclean comes to the pharmacy seeking help to manage his hayfever symptoms in the run-up to important A-level exams. Todd complains of particularly severe nasal symptoms including sneezing, a runny nose, nasal congestion and post-nasal drip, all of which are affecting his ability to get a good night’s sleep.
Todd is not alone, as recent reports suggest nearly two-thirds of hayfever sufferers experience allergic symptoms that negatively impact on their sleep.6 On average, those affected may lose more than an hour of sleep each night as they struggle to contend with hayfever symptoms.
This problem of nocturnal symptoms is thought to occur because, although pollen rises into the lower atmosphere during the course of the day, it begins to fall back towards ground level as the temperature drops, so many hayfever sufferers may actually be exposed to higher levels of pollen in the evening compared to earlier in the day.
Advise Todd to keep his windows shut at night and first thing in the morning to reduce the amount of pollen that can enter the house. He could also try showering, washing his hair and changing his clothes as soon as he arrives home from college to avoid tracking pollen into the bedroom. Some customers who suffer from indoor allergies also find that an air filter can help to alleviate symptoms by trapping small particles of pollen that penetrate into the house.
The specific nasal symptoms of hayfever occur when IgE antibodies generated by the body in response to pollen trigger the release of inflammatory mediators, which irritate the lining of the throat and nose. As Todd’s nasal symptoms are proving particularly problematic, you could recommend use of an allergen barrier balm or gel nasal spray (or even just plain petroleum jelly) applied around the nostrils to help prevent pollen entering the nose. Nasal rinsing with a normal saline solution may also help to remove pollen and allergens from the nose.
When considering treatment advice, it is important to establish the specific details of Todd’s nasal hayfever symptoms and whether his main complaint is a runny nose or a blocked/congested nose. Antihistamine products are most effective against sneezing and an itchy and/or runny nose, but work less well for a blocked nose.3
If Todd does decide to try OTC antihistamines, suggest he takes them in the early evening before bed. This will help to combat hayfever symptoms throughout the night and potential medication side-effects such as drowsiness (although uncommon) could help him to get a better night’s sleep.
For blocked nose symptoms of hayfever, steroid nasal sprays are the preferred treatment option. Ideally, these should be used for one to two weeks before the onset of symptoms for maximum efficacy. If Todd’s nasal symptoms are proving particularly severe and/or fail to respond to OTC medication, suggest he visits his GP, as a combined steroid and antihistamine nasal spray may be another potential treatment option.
Elodie Hayes has pre-existing asthma but also suffers from a birch pollen allergy. After being hospitalised for a severe asthma exacerbation last summer, Elodie is worried about how the impending hayfever season may affect her asthma symptoms. She wants to know how best to avoid and manage potential asthma flare-ups triggered by pollen.
Elodie is right to be concerned, as asthma and hayfever are intrinsically linked under the pathophysiological concept of ‘one airway, one disease’.7 The majority of asthma patients (around 80 per cent) are allergic to pollen and this airborne allergen can act as a potent asthma trigger, with the release of histamine that characterises hayfever exacerbating asthma symptoms.8
The blocked nose often associated with hayfever can also affect asthma control. Rather than breathing air through the nose that is warmed and moistened before coming into contact with the lungs, patients are forced to breath in colder drier air through the mouth, which can then sensitise the airways.8 Several studies have implicated seasonal factors in deaths from asthma and the influence of hayfever on asthma mortality seems particularly evident among young people.7
You could suggest that Elodie keeps a diary to identify whether pollen is a trigger for her asthma symptoms and takes the basic steps to reduce pollen exposure that would be recommended to any hayfever sufferer. Reassure Elodie that the best way of reducing the risk of pollen-induced flare-ups is by keeping her asthma symptoms under good control. Key self-care measures include taking her asthma medication regularly, using her written asthma action plan and attending regular asthma reviews.
Evidence also shows that asthma patients can significantly reduce their risk of visiting A&E or requiring hospitalisation for pollen-induced exacerbations if they treat their hayfever with effective OTC products such as nasal sprays, antihistamines or anti-inflammatory eye drops.8 The pharmacy can advise Elodie on the best hayfever treatments to suit her particular range of symptoms.
Hayfever often proves problematic during pregnancy
1. UK Teratology Information Service (UKTIS). Decongestants. Available at: medicinesinpregnancy.org/Medicine--pregnancy/Decongestants
2. NHS Choices: nhs.uk/pages/home.aspx
3. Allergy UK: allergyuk.org
4. Patient UK: patient.info
5. The Guardian. Have I got hayfever – or another kind of allergy? Article published April 2016. Available at: theguardian.com/lifeandstyle/2015/apr/05/have-i-got-hay-fever-another-allergy-runny-nose-itchy-eyes
6. Daily Mail. Why hayfever gets worse as you go to bed. Article published June 2015. Available at: dailymail.co.uk/health/article-3139074/Do-insneezia-Two-thirds-hay-fever-sufferers-battle-symptoms-NIGHT-losing-hour-s-sleep-average.html
7. Marsh V. Effective techniques for asthma control in hayfever season. Independent Nurse, published May 2016. Available at: independentnurse.co.uk/clinical-article/effective-techniques-for-asthma-control-in-hay-fever-season/141291
8. Asthma UK. Pollen. Available at: asthma.org.uk/advice/triggers/pollen