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Allergies Ear, nose and throat Respiratory

Allergic rhinitis

Last revised in January 2024

Allergic rhinitis is an inflammatory disorder of the nose which occurs when the membranes lining the nose become sensitized to allergens.

Allergic rhinitis: Summary

Allergic rhinitis is an IgE-mediated, inflammatory disorder of the nose that occurs when the nasal mucosa becomes exposed and sensitized to allergens, to produce typical symptoms of sneezing, nasal itching, rhinorrhoea, and congestion.
Allergic rhinitis may be classified by severity (mild or moderate to severe), or as:
- Seasonal — symptoms occur at the same time each year. If caused by grass and tree pollen allergens, it is also known as 'hay fever'.
- Perennial — symptoms occur throughout the year, typically due to allergens from house dust mites and animal dander.
- Intermittent — symptoms occur for less than four days a week, or less than four consecutive weeks.
- Persistent — symptoms occur for more than four days a week and for more than four consecutive weeks.
- Occupational — symptoms due to exposure to allergens in the work environment.
Allergic rhinitis is common, affecting around 23–30% of the population in Europe. It usually begins in childhood and adolescence.
Complications include reduced quality of life, impaired school and work performance, disturbed sleep, reduced concentration, and possible development of asthma, sinusitis, and nasal polyps.
A diagnosis of allergic rhinitis should be suspected if there are typical clinical features:
- Classic symptoms that occur following exposure to a known causative allergen.
- Possible associated allergic conjunctivitis, asthma, or eczema.
Assessment of a person with suspected allergic rhinitis should include:
- The type, frequency, timing, persistence, and location of symptoms.
- The severity and impact of symptoms.
- Housing conditions, pets, and occupation.
- Any drugs that may cause, aggravate, or alleviate symptoms.
- Any family history of atopy.
- Examination for signs and underlying causes of rhinitis, and/or associated conditions.
Initial management of allergic rhinitis should include advice on:
- Sources of information and support.
- Possible use of saline nasal irrigation.
- Allergen avoidance techniques if there is an identified causative allergen.
- The use of as-needed intranasal antihistamine or non-sedating oral antihistamine for symptoms that are mild, intermittent, or both.
- The use of regular intranasal corticosteroids during periods of allergen exposure for moderate to severe persistent symptoms, or if initial drug treatment is ineffective.
- Arranging review after 2–4 weeks if symptoms persist.
Management of refractory allergic rhinitis should include offering:
- A combination intranasal antihistamine and corticosteroid spray.
- Possible add-on treatments, such as an intranasal decongestant, intranasal anticholinergic, or leukotriene receptor antagonist.
- A short course of oral corticosteroid for severe, uncontrolled symptoms in adults that are significantly affecting quality of life.
Referral to an allergy or ear, nose, and throat specialist should be arranged if:
- There are red flag features suggesting an alternative or serious diagnosis.
- There are persistent symptoms despite optimal management in primary care.
- Allergen avoidance techniques such as house dust mite or animal dander avoidance are being considered, as allergy testing may be needed.
- The person would like to consider immunotherapy treatment instead of long-term medication.
- The diagnosis is uncertain, as allergy testing or other investigations may be needed.

Have I got the right topic?

From age 24 months onwards.

This CKS topic covers the diagnosis and management of allergic rhinitis, including perennial, seasonal, and occupational rhinitis.

There are separate CKS topics on Asthma, Eczema - atopic, Conjunctivitis - allergic, and Sinusitis.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

January 2024 — minor update. Cetirizine doses for people with renal impairment updated in line with manufacturer's SPC.

Previous changes

October 2023 — reviewed. A literature search was conducted in August 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone minor restructuring. Recommendations in the Management section have been updated in line with current literature. Information on risk factors and on prescribing intranasal corticosteroids and the combined intranasal corticosteroid with antihistamine sprays has been added. The section on prescribing intranasal chromones has been removed as these are not available in the UK.

June 2023 — minor update. Cetirizine doses for people with renal impairment updated in line with BNF.

December 2022 — minor update. Removed the decongestant ephedrine 0.5% as these have been discontinued.

August 2021 — minor update. Recommendations on use of cetirizine in people with renal impairment have been updated in line with the updated manufacturer's Summary of Product Characteristics.

July to September 2018 — reviewed. A literature search was conducted in July 2018 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone minor restructuring. The Scenarios have been merged into one Scenario, and recommendations in the Management section have been updated in line with current literature. The section on Prescribing information has been updated and expanded.

January 2018 — minor update. The section on the adverse effects of non-sedating antihistamines has been updated to reflect changes to the manufacturer's Summary of Product Characteristics (SPC).

May 2017 — minor update. Information regarding the expected increased risk of systemic adverse effects after co-treatment with CYP3A inhibitors, including cobicistat-containing products has been added to reflect an update to the manufacturer's Summary of Product Characteristics (SPC).

October 2015 — minor update. The licensing information on mometasone (Nasonex^®) has been amended in line with the manufacturer's Summary of Product Characteristics (SPC); it is now licensed for use in people from the age of 3 years (previously from 6 years onwards) and for the treatment of nasal polyps in adults 18 years of age and older.

June 2015 — minor update. Information on the choice of intranasal corticosteroids has been updated to include the licensed ages. In addition, flunisolide has been removed as an option because it has been discontinued by the manufacturer.

June 2014 — minor update. Typographical errors corrected, and the topic summary was reformatted.

November 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to clinical recommendations have been made.

September 2012 — minor update. Ephedrine 0.5% nasal drops are no longer licensed for use in children younger than 12 years of age. Text and prescriptions have been updated.

June 2012 — minor update. Typographical error corrected.

January 2011 — topic structure revised to ensure consistency across CKS topics. No changes to clinical recommendations have been made.

August 2009 — minor update. Xylometazoline 0.05% nasal drops (Otrivine Child Nasal Drops^®) are no longer licensed for use in children between 2 and 5 years of age. They can be prescribed for children who are 6 years of age and over.

June 2009 — minor formatting correction.

October 2007 to January 2008 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. The previous system of classifying a person with allergic rhinitis by the persistence and severity of their symptoms to determine management has been modified. Management is now divided into whether or not a person with symptoms of allergic rhinitis is presently on treatment, and this is reflected in the scenarios offered.

July 2006 — minor update. Levocabastine products discontinued and prescriptions removed.

May 2006 — minor update. Montelukast now licensed for symptomatic relief of seasonal allergic rhinitis in people with asthma in whom montelukast is indicated. Text and prescriptions updated to reflect this.

February 2006 — minor update. Black triangle removed from desloratadine.

November 2005 — minor technical update.

July 2005 — updated to include sodium cromoglicate eye drops for use in pregnancy.

December 2004 — rewritten. Validated in March 2005 and issued in April 2005.

December 2001 — rewritten, replacing the previous topic Allergic rhinitis/hay fever. Validated in March 2002 and issued in April 2002.

September 1998 — written.

Update

New evidence

Evidence-based guidelines

NICE (2025) 12 SQ-HDM SLIT for treating allergic rhinitis and allergic asthma caused by house dust mites. National Institute for Health and Care Excellence https://www.nice.org.uk [Free Full-text]
NICE (2026) 12 SQ-Bet SLIT for treating moderate to severe allergic rhinitis or conjunctivitis caused by tree pollen in people 5 years and over. National Institute for Health and Care Excellence https://www.nice.org.uk [Free Full-text]
NICE (2026) 12 SQ-HDM SLIT for treating allergic rhinitis and allergic asthma caused by house dust mites. National Institute for Health and Care Excellence https://www.nice.org.uk [Free Full-text]

HTAs (Health Technology Assessments)

NICE (2025) Betula verrucosa for treating moderate to severe allergic rhinitis or conjunctivitis caused by tree pollen – guidance TA1087. National Institute for Health and Care Excellence. [Free Full-text]

Economic appraisals

No new economic appraisals relevant to England since 1 August 2023.

Systematic reviews and meta-analyses

Sousa-Pinto, B., Vieira, R. J., Brozek, J., et al. (2024). Intranasal antihistamines and corticosteroids in allergic rhinitis: A systematic review and meta-analysis. Journal of Allergy and Clinical Immunology. [Abstract]

Primary evidence

No new randomized controlled trials published since 1 August 2023.

New policies

No new national policies or guidelines since 1 August 2023

New safety alerts

No new safety alerts since 1 August 2023.

Changes in product availability

Distaclor (cefaclor) MR Tablets, Capsules and Suspensions. SPC updated following reports of neurotoxicity being identified in association with cephalosporin treatment. Symptoms may include encephalopathy, myoclonus & seizures. If cefaclor associated neurotoxicity is suspected, discontinuation should be considered. See more here.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

Make an accurate diagnosis of allergic rhinitis.
Offer appropriate management in primary care.
Refer people with refractory symptoms to an immunology or ear, nose, and throat (ENT) specialist if appropriate, depending on clinical judgement.
Provide self-management advice and information to parents and carers, if needed.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

Allergic rhinitis is an IgE-mediated inflammatory disorder of the nose that occurs when the nasal mucosa becomes exposed and sensitized to allergens.
- Rhinitis describes inflammation of the nasal mucosa, which causes typical clinical symptoms of sneezing, nasal discharge (rhinorrhoea), itching, and congestion.
- Rhinitis may be allergic, non-allergic, infective, or mixed.
- Where the sinuses are also involved, the condition is known as rhinosinusitis.
- When the eyes are also involved, the term rhinoconjunctivitis is used.
- Allergic rhinitis is mediated by the antibody IgE. Allergens; such as pollens, house dust mites, mould, or pet dander, trigger an abnormal IgE reaction in the nasal mucosa, triggering the release of histamine and other inflammatory mediators, which act on cells, nerve endings, and blood vessels to produce typical symptoms of rhinitis described above.

Allergic rhinitis may be classified according to duration and severity.
- Duration:
  - Intermittent — Symptoms are present less than four days a week or for less than four weeks.
  - Persistent — Symptoms are present at least four days a week and for at least four weeks.
- Severity — depending on the impact of the condition on sleep and daily activities.
  - Mild — No disturbance of sleep or daily living activities.
  - Moderate to severe — Sleep and/or daily living activities affected (sleep disturbance, impairment of school, work, leisure or sport, or otherwise troublesome symptoms.)
Allergic rhinitis can also be classified as seasonal or perennial. This may be inconsistent, however, and clinically it may be more useful to use the intermittent or persistent classification above.
- Seasonal rhinitis — Symptoms occur at the same time each year in response to a seasonal allergen. When triggered by grass or tree pollen, it is also known as 'hay fever' and most typically occurs in summer months, although, depending on the pollen, it may occur at other times of the year. It is usually accompanied by allergic conjunctivitis.
- Perennial rhinitis — Symptoms occur throughout the year, typically due to allergens from house dust mites and animal dander. Symptoms will vary with the environment, however.
Occupational rhinitis describes rhinitis mediated by airborne substances in the work environment, and may be either allergic or non-allergic.

[Brozek, 2017; Scadding, 2017; Euforea, 2021a; Euforea, 2021b; Stonham, 2022; BMJ Best Practice, 2023]

What causes it?

The development of allergic rhinitis is mediated by genetic and environmental factors [Barr, 2014; Scadding, 2017; Wise, 2023].

Genetic predisposition is an important factor in rhinitis development, and it is highly heritable [Scadding, 2017; BMJ Best Practice, 2023]. Large genome-wide association studies (GWAS) have identified multiple risk loci and genes that may be involved in the disease mechanism [Portelli, 2015; Waage, 2018].
A Swedish prospective, longitudinal cohort study (n = 8176 families) found the common odds ratio of developing parental-reported allergic rhinitis was 2.21 if the parents had a history of rhinitis [Alm, 2011].

Common environmental triggers include [EAACI, 2015]:

House dust mites
- These feed on shed human skin flakes, which are particularly abundant in mattresses, bed bases, pillows, carpets, upholstered furniture, and furry toys.
- They thrive in conditions of high humidity.
- They are present all year-round, but their numbers tend to peak in the spring and autumn.
Grass, tree, and weed pollens
- The length, duration, and intensity of the pollinating season varies from year to year, which can complicate the identification of the responsible allergen.
  - Trees generally pollinate in the spring.
  - Grasses pollinate at the end of spring and the beginning of summer.
  - Weeds may pollinate from early spring to late autumn.
Moulds
- Indoor moulds such as Alternaria, Cladosporium, and Aspergillus may be associated with damp environments.
Animal dander
- Cat and dog hair are the most common animal allergens, which cause perennial symptoms.
- Less commonly, dander from horses, cattle, rabbits, and rodents (such as guinea pigs, hamsters, and rats) may cause allergic rhinitis.
Occupational
- The incidence of allergic rhinitis is increased in certain occupations, such as working with latex gloves, chlorine, flour, wood dust, or laboratory animals.
- Typically, there is a defined latency period of months to years, during which sensitization to a causal agent occurs.

What are the risk factors?

Risk factors for developing allergic rhinitis include:

Family history of atopy, particularly allergic rhinitis.
Food allergy in childhood.

[Bousquet, 2020a; BMJ Best Practice, 2023; Wise, 2023]

How common is it?

Allergic rhinitis is common and the prevalence has increased worldwide since the 1960s [Bousquet, 2020a].

Allergic rhinitis affects up to 50% of the population worldwide, and 23–30% of the population in Europe [EAACI, 2015; Scadding, 2021; Wise, 2023].
Reported prevalence rates vary widely, which may be partly due to the lack of uniformity of terminology and diagnostic criteria used in the studies [Wise, 2023].
A large three-phase international study on asthma and allergies in childhood published in 2006 showed that prevalence in children varied between 0.8% and 14.9% in 6 to 7-year-olds, and between 1.4% and 39.7% in 13 to 14-year-olds [Asher, 2006; Bousquet, 2020a]. The authors reported a worldwide variation in prevalence.
A population-based survey published in 2004 found the prevalence in adults to be 26% in the UK [Bauchau, 2004].
A UK primary healthcare database review (1999–2005) found that 10% of 6 and 7-year-olds, and 15–19% of 13 and 14-year-olds, are affected by allergic rhinitis in England [Ghouri, 2008]. The age-sex standardized incidence of allergic rhinitis was 5.57 per 1000 person-years in 2001, and increased by 33.0% to 7.41 per 1000 person-years in 2005. Lifetime age-sex standardized prevalence of a recorded diagnosis of allergic rhinitis increased by 43.2% from 46.35 per 1000 in 2001 to 66.37 per 1000 in 2005 [Ghouri, 2008].
Allergic rhinitis is more common in males before puberty, but more common in females after puberty [Bousquet, 2020a].
It is unusual for infants to develop allergic rhinitis in the first two years of life. It may be, therefore, that more than one season of allergen exposure is needed for sensitization to occur. It has been estimated that between the ages of 3 and 12, new cases of seasonal allergic rhinitis increase at a constant rate of around 2% per year [Euforea, 2021b; Scadding, 2021].

What are the complications?

Complications of allergic rhinitis include:

Impaired quality of life — allergic rhinitis can adversely affect work, home, and social life, especially during the peak pollen season [Roberts, 2013; Brozek, 2017; Lipworth, 2017; Wise, 2023].
Sleep disturbance [Bousquet, 2020a; Wise, 2023].
Impaired school performance — poorly controlled symptoms in children may cause difficulty concentrating, irritability, and sleep disturbance [Roberts, 2013; Brozek, 2017; Lipworth, 2017].
Asthma — allergic rhinitis and asthma often co-exist, and allergic rhinitis is a risk factor for the development of asthma [Roberts, 2013; Barr, 2014; Brozek, 2017; Lipworth, 2017]. See the CKS topic on Asthma for more information.
- An Australian longitudinal cohort study of children (n = 7383) found that allergic rhinitis in childhood was associated with a seven-fold increased risk of asthma in the pre-adolescent period, and a three-fold increased risk of asthma persisting into adulthood [Burgess, 2007]. The 2016 revision of the Allergic Rhinitis and its Impact on Asthma (ARIA) international guideline notes that asthma is found in 15–38% of people with allergic rhinitis [Brozek, 2017].
- Co-morbid allergic and non-allergic rhinitis affects over 80% of people with asthma [Stonham, 2022]. People with asthma with severe rhinitis symptoms are four times more likely to have poorly controlled asthma than those without [Scadding, 2012].
- The concept of a 'unified airway disease' has arisen due to the associations and links between upper and lower airways and between rhinitis and asthma [Wise, 2023].
Allergic conjunctivitis — there are high rates of co-morbidity with allergic rhinitis and allergic conjunctivitis, particularly in those with persistent seasonal pollen allergy, with studies quoting 30–95% of those with allergic rhinitis reporting associated eye symptoms [Wise, 2023]. See the CKS topic Allergic conjunctivitis for more information.
Sinusitis and nasal polyps — sinusitis is a common complication of allergic rhinitis. It is thought that swelling of the nasal mucosa leads to obstruction of the drainage of the sinuses, predisposing to the development of sinusitis [Lipworth, 2017]. See the CKS topic on Sinusitis for more information.
Obstructive sleep apnoea syndrome (OSAS) — Allergic rhinitis may contribute to the worsening of OSAS or may additionally affect sleep in patients with OSAS [EAACI, 2015]. See the CKS topic on Obstructive sleep apnoea syndrome.
Oral allergy syndrome (pollen-food syndrome) — allergic rhinitis can be associated with oral allergy syndrome, where symptoms of oral itching and swelling occur due to cross-reactivity between aeroallergens, such as birch pollen and vegetables and fruits such as apples [Roberts, 2013; Euforea, 2021b].

What is the prognosis?

A prospective questionnaire survey of children aged 3–17 years with a confirmed diagnosis of allergic rhinitis (n = 154) found that the condition had resolved in only 10% of children after 8–11 years [Linna, 1992]. The 2016 revision of the Allergic Rhinitis and its Impact on Asthma (ARIA) international guideline notes that it is a condition that usually persists throughout life [Brozek, 2017].
However, pharmacological treatment is effective in most patients and can improve the quality of life [Bousquet, 2020a; Wise, 2023].

Diagnosis of allergic rhinitis

When should I suspect allergic rhinitis?

Suspect a diagnosis of allergic rhinitis if alternative causes for rhinitis have been excluded, and a person presents with typical clinical features:
- Classic symptoms of sneezing, nasal itching, nasal discharge (rhinorrhoea), and nasal congestion — bilateral symptoms typically develop within minutes following allergen exposure.
- Additional symptoms such as postnasal drip, itching of the palate, and cough, and features suggestive of chronic nasal congestion, such as snoring, mouth breathing, and halitosis.
- Associated eye symptoms such as bilateral itching, redness, and tearing. See the CKS topic on Conjunctivitis - allergic for more information.
- A personal or family history of atopy (asthma, eczema, or allergic rhinitis). See the CKS topics on Asthma and Eczema - atopic for more information.
- Symptoms that occur following exposure to a known causative allergen, such as:
  - Tree pollens — intermittent or chronic symptoms occur from early to late spring.
  - Grass pollens — intermittent or chronic symptoms occur from late spring to early summer.
  - Weed pollens — intermittent or chronic symptoms may occur from early spring to early autumn.
  - House dust mites — symptoms are worse on waking and are present all year-round, but may peak in autumn and spring.
  - Animal dander — symptoms follow exposure to animal dander, and may be all year-round or occasional, depending on exposure.
  - Occupational — intermittent or chronic symptoms tend to improve when the person is away from work, such as weekends and holidays.
- Note: be aware that allergic and irritant rhinitis may co-exist, as chemical irritants may aggravate underlying allergic rhinitis.

Basis for recommendation

These recommendations are based on the Allergic Rhinitis and its Impact on Asthma (ARIA) international guidelines (2016 revision) [Brozek, 2017], expert opinion in the British Society of Allergy and Clinical Immunology guideline BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis [Scadding, 2017], a primary care expert consensus statement [Lipworth, 2017], a 2023 international consensus statement [Wise, 2023], and expert opinion in review articles on allergic rhinitis and occupational rhinitis, Primary care: the cornerstone of diagnosis of allergic rhinitis [Ryan et al, 2008], Allergic rhinitis in children [Barr, 2014], Allergic rhinitis [Akhouri, 2023], and Occupational rhinitis: an update [Stevens, 2015].

How should I assess a person with suspected allergic rhinitis?

If a diagnosis of allergic rhinitis is suspected, assess the person to help guide appropriate management.

Ask about:
- The type, timing, frequency, persistence, and location of symptoms (indoors or outdoors). Ask whether symptoms are unilateral or bilateral. (Unilateral symptoms are more likely to be due to another cause of blockage, such as polyps, foreign body, carcinoma, or cerebrospinal fluid leak.)
- The severity of symptoms and impact on the person's quality of life, including sleep, concentration, mood, behaviour, fatigue, and its impact on leisure activities, school, and work.
- Housing conditions, pets, and occupation, to identify possible causative triggers and allergens.
  - Occupational history should include the nature of the job; duration of employment before symptoms developed; agents exposed to at work; and whether symptoms improve when the person is away from work such as weekends and holidays.
  - Note: people may be allergic to one or more allergens.
- Symptoms that could suggest an alternative diagnosis. (These include unilateral symptoms, discoloured nasal discharge, recurrent nosebleeds, facial or nasal pain, or loss of sense of smell. Also, children under the age of 2 with continuous symptoms of rhinitis).
- Symptoms suggesting associated conditions such as allergic conjunctivitis, asthma, eczema, sinusitis, and obstructive sleep apnoea syndrome and manage accordingly. See the CKS topics on Conjunctivitis - allergic, Asthma, Eczema - atopic, Sinusitis, and Obstructive sleep apnoea syndrome for more information.
  - Be aware that respiratory symptoms such as cough, wheeze, and breathlessness may be solely due to rhinitis rather than asthma, as bronchial hyper-reactivity may be induced by upper airway inflammation.
- Medication history: Any drugs that may cause or aggravate symptoms; previous treatments and their effectiveness, including over-the-counter treatments such as antihistamines and intranasal corticosteroids.
- Any family history of atopy.
Examine for signs and underlying causes of rhinitis, and/or associated conditions:
- Nasal intonation of the voice.
- Mouth-breathing.
- Darkened eye shadows under the lower eyelid due to chronic congestion (so-called 'allergic shiners').
- Horizontal nasal crease across the dorsum of the nose (seen in severe rhinitis).
- Deviated or perforated nasal septum and depressed or widened nasal bridge.
- Nasal mucosa swelling and greyish discolouration with excessive clear secretions (typically seen in allergic rhinitis); nasal polyps (rare in children); hypertrophic nasal turbinates (suggests inflammation); and foreign bodies.
- Purulent nasal discharge suggesting sinusitis. See the CKS topic on Sinusitis for more information.
- Eye involvement suggesting allergic conjunctivitis. See the CKS topic on Conjunctivitis - allergic for more information.
- Note: the nasal appearance may be normal in people with allergic rhinitis.
- Growth should be assessed in children. (Severe airway disease may impact growth, as may the use of corticosteroids at multiple sites.) Measure height on presentation, in order to be able to monitor this, particularly children already on or starting corticosteroids in any form.
Allergic rhinitis can usually be diagnosed from the clinical history, supported by nasal examination and a response to first line treatment. Further investigations are usually only required if the allergen causing the symptoms can be avoided (as these measures can be problematic), if there are elements in the history or examination leading to diagnostic doubt, or if there is a lack of response to treatment.

Basis for recommendation

The recommendations on assessment are based on expert opinion in the British Society of Allergy and Clinical Immunology guideline BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis [Scadding, 2017], a primary care expert consensus statement An algorithm recommendation for the pharmacological management of allergic rhinitis in the UK [Lipworth, 2017], the European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) pocket guides for allergic rhinitis in adults and children [Euforea, 2021a; Euforea, 2021b], the British Medical Journal (BMJ) Best Practice guide Allergic rhinitis [BMJ Best Practice, 2023], and expert opinion in review articles on allergic rhinitis, Allergic rhinitis in children [Barr, 2014], Allergic rhinitis [Bousquet, 2020a], Allergic rhinitis in childhood and the new EUFOREA algorithm [Scadding, 2021], Allergic rhinitis: a common problem, not to be sneezed at! [Stonham, 2022], and on occupational rhinitis, Occupational rhinitis: an update [Stevens, 2015].

Investigations

A therapeutic trial of first-line treatment may be considered as the first investigation or diagnostic tool when the history is typical.
Specialist allergy testing may involve skin prick testing or measuring the levels of serum-specific immunoglobulin E (IgE) to allergens such as house dust mites, pollen, and animal dander (radioallergosorbent test [RAST]).
- Skin prick testing may help to differentiate between allergic and non-allergic rhinitis, and has a high negative predictive value. It has a better positive predictive value than serum testing, and provides immediate results. However, results may be suppressed by recent antihistamine, tricyclic antidepressant (TCA), and topical corticosteroid use. Up to 15% of people with a positive skin prick test do not develop symptoms on exposure to the relevant allergen, and therefore positive tests alone do not confirm the causative allergen in the absence of a supportive history.
- Serum IgE testing may be used when skin prick testing is not possible or provides equivocal results. IgE levels do not necessarily relate to the degree of clinical reaction.
Other specialist investigations may be required where there is diagnostic doubt or failure to respond to treatment, such as:
- Nasal endoscopy.
- Nasal allergen challenge.
- Evaluation of nasal nitric oxide and ciliary beat frequency.
- Analysis of nasal fluid.
- CT scans.

Basis for recommendation

This information is based on the British Society of Allergy and Clinical Immunology (BSACI) Guideline for the diagnosis and management of allergic and non-allergic rhinitis [Scadding, 2017], the British Medical Journal (BMJ) Best Practice guide Allergic rhinitis [BMJ Best Practice, 2023], and expert opinion in review articles, Allergic rhinitis [Bousquet, 2020a], Allergic rhinitis in childhood and the new EUFOREA algorithm [Scadding, 2021], and Allergic rhinitis: a common problem, not to be sneezed at! [Stonham, 2022].

What else might it be?

Alternative causes for rhinitis may include:

Infective rhinitis
- Symptoms have a typical onset of one week or less, with typical features of an associated viral upper respiratory tract infection, such as cough, fever, or lymphadenopathy. If nasal discharge is clear, infection is less likely. See the CKS topic on Common cold for more information.
Non-allergic rhinitis
- Autonomic or irritant rhinitis
  - Symptoms typically follow a known physical exposure (changes in temperature or humidity, or with exercise) or chemical irritant exposure (volatile chemicals such as perfumes, tobacco smoke, and odours). These triggers cause nasal airway hyper-reactivity through a non-IgE mediated pathway.
- Drugs
  - A number of drugs may cause or aggravate rhinitis symptoms, such as alpha-blockers, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, chlorpromazine, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), phosphodiesterase inhibitors, and cocaine.
  - Rebound symptoms and a paradoxical increase in nasal congestion may occur when stopping prolonged treatment with intranasal decongestants due to rebound vasodilatation (so-called 'rhinitis medicamentosa'). See the section on Intranasal decongestants in Prescribing information for more information.
- Endocrine
  - Hormonal rhinitis should be considered when symptoms coincide with pregnancy, starting the oral contraceptive pill, hormone replacement therapy (HRT), or hypothyroidism. See the CKS topics on Contraception - combined hormonal methods and Hypothyroidism for more information.
- Food and drink
  - Alcohol, sulphites, and spicy foods may cause rhinorrhoea and facial flushing.
- Non-allergic rhinitis with eosinophilia syndrome (NARES)
  - This rare condition is a diagnosis of exclusion characterized by nasal eosinophils in people with perennial symptoms, and sometimes reduced sense of smell.
  - 50% of people develop aspirin-sensitive disease with asthma and nasal polyposis later in life.
  - NARES is a risk factor for developing or exacerbating obstructive sleep apnoea.
- Occupational rhinitis
  - Occupational rhinitis may be allergic or non-allergic, and is due to a cause in a particular work environment.
  - Non-allergic causes include perfumes, smoke, formaldehyde, ammonia, and acids causing irritation or having corrosive effects.
  - Examples of allergic causes are flour, animals, latex, animal-related allergens, fish, and biological enzymes.
- Systemic
  - May be caused by primary defects in mucus production (for example cystic fibrosis), primary ciliary dyskinesia (Kartagener syndrome), and granulomatous disease (for example granulomatosis with polyangiitis [previously known as Wegener's granulomatosis] and sarcoidosis).
- Structural
  - Typically caused by deviated nasal septum, nasal polyps, hypertrophic turbinates, adenoidal hypertrophy, foreign body, or cerebrospinal fluid (CSF) leak (rare).
  - Sinonasal tumour (rare) should be excluded if there are unilateral symptoms, recurrent bloody nasal discharge or nosebleeds, nasal pain, anosmia, or visual disturbance. See the CKS topic on Epistaxis (nosebleeds) for more information.
  - Aging may cause morphological and functional changes in the nose, which may cause symptoms of rhinitis in older people.

Basis for recommendation

The information on the differential diagnoses of allergic rhinitis is based mainly on the International consensus statement on allergy and rhinology: Allergic rhinitis - 2023 [Wise, 2023], and also on the 2008 version of the Allergic Rhinitis and its Impact on Asthma (ARIA) international guideline [Bousquet, 2008], the European Academy of Allergy and Clinical Immunology's (EAACI) Global Atlas of Allergic Rhinitis and Chronic Rhinosinusitis [EAACI, 2015], and expert opinion in the British Society of Allergy and Clinical Immunology guideline BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis [Scadding, 2017].

Management

Scenario: Management

From age 24 months onwards.

What self-management strategies should I advise?

If a person has a diagnosis of allergic rhinitis:

Provide advice on sources of information and support, such as:
- The Allergy UK factsheets on Hay fever (Allergic Rhinitis) and Improving your indoor air quality.
- The NHS patient information leaflets Allergic rhinitis and Hay fever.
Advise the person to consider the use of nasal irrigation with saline to rinse the nasal cavity using a spray, pump, or squirt bottle, which can be purchased over-the-counter.
Provide advice on allergen avoidance techniques if there is a specific identified causative allergen:
- For people with pollen allergy, advise to:
  - Avoid walking in grassy, open spaces, particularly during the early morning, early evening, and during mowing, when the pollen count is high.
  - Avoid drying washing outdoors when the pollen count is high.
  - Keep windows shut in cars and buildings when the pollen count is high.
  - Plan holidays to avoid the pollen season, where possible.
  - Shower or wash hair following high pollen exposures.
  - Consider the use of sunglasses (ideally wraparound) or nasal barriers (masks covering the nose and mouth or commercially available powders, balms or creams rubbed on the nose) when the pollen count is high.
  - Consider monitoring the pollen count using a website such as the Met Office so that avoidance measures can be used when pollen counts are high.
- For people with confirmed house dust mite allergy following allergy testing, advise to:
  - Not fit mattresses, pillows, and duvets with house dust mite impermeable covers.
  - Use synthetic pillows and acrylic duvets, and keep furry toys off the bed.
  - Wash all bedding and furry toys at least once a week at high temperatures.
  - Choose wooden or hard floor surfaces instead of carpets, if possible.
  - Fit blinds that can be wiped clean instead of curtains. Surfaces should be wiped regularly with a clean, damp cloth.
- For people with confirmed animal allergy following allergy testing, advise to:
  - Ideally not allow the animal in the house. If this is not acceptable or possible, advise restricting their presence to the kitchen.
  - Wash the animal and any surfaces they are in contact with, regularly.
- For people with occupational allergies, advise to:
  - Avoid exposure to allergen completely where possible.
  - If elimination or complete avoidance of the allergens is not possible, reduce exposure to both known and potentially sensitizing allergens in the workplace, for example, by using latex-free gloves, wearing protective clothing, or a dust mask.
  - Ensure that their work environment is adequately ventilated and/or relocating to lower exposure areas in the workplace.
  - Use less hazardous chemicals, if possible and appropriate.

Basis for recommendation

The recommendations on self-management strategies are based expert opinion in the British Society of Allergy and Clinical Immunology guideline BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis [Scadding, 2017], a primary care expert consensus statement An algorithm recommendation for the pharmacological management of allergic rhinitis in the UK [Lipworth, 2017], the International consensus statement on allergy and rhinology: Allergic rhinitis - 2023 [Wise, 2023], the Cochrane systematic reviews House dust mite avoidance measures for perennial allergic rhinitis: an updated Cochrane systematic review [Nurmatov, 2012] and Saline irrigation for allergic rhinitis [Head, 2018], and expert opinion in review articles on allergic rhinitis Perennial rhinitis [Saleh, 2007], Allergic rhinitis in children [Barr, 2014], and Allergic rhinitis: a common problem, not to be sneezed at! [Stonham, 2022], and on occupational rhinitis Occupational rhinitis: an update [Stevens, 2015].

Advice on pollen allergen avoidance

The recommendations on grass pollen avoidance are largely pragmatic based on very limited evidence, but are recommended in the BSACI guideline [Scadding, 2017], which points out that allergen avoidance where possible is effective, given that people with seasonal hay fever are asymptomatic outside of the pollen season.
A 2023 international consensus statement reviewed the evidence for pollen avoidance strategies (such as wraparound sunglasses, nasal filters, cellulose powder applied to the nose, and pollen blocker cream) and concluded that there was some evidence for symptomatic benefit and reduced use of medication and that the lower cost strategies may be beneficial, but that more studies are needed to define this [Wise, 2023].
Practical tips on finding information about pollen count are based on expert opinion in a review article from the Primary Care Respiratory Society, Allergic Rhinitis: A common problem, not to be sneezed at [Stonham, 2022].

Advice on animal dander allergen avoidance

The 2010 revision of the ARIA guideline strongly recommends people with allergic rhinitis caused by animal dander should avoid exposure to these allergens at home, based on very low-quality evidence [Brozek et al, 2010]. Subsequent updates have been targeted at pharmacological treatments and have not addressed this issue. This approach was supported by the 2013 Paediatric rhinitis: position paper of the European Academy of Allergy and Clinical Immunology [Roberts, 2013] and expert opinion in a narrative review article that affected people should be discouraged from having pets in the home, Perennial rhinitis [Saleh, 2007].
Expert opinion in an additional review narrative review article, Allergic rhinitis in children [Barr, 2014], recommends animals should be washed regularly, as should all surfaces in potential contact with animal dander .
A 2023 international consensus statement reviewed the evidence for allergen avoidance relating to pets and found it to be of low quality, and that pet washing has to be completed twice weekly to maintain significant reductions in allergens. Benefit to harm ratio for these measures was found to be equivocal [Wise, 2023].

If a person has a diagnosis of allergic rhinitis, advise on self-management strategies and drug treatment options. Most local policies restrict prescribing for seasonal allergic rhinitis and patients are encouraged to buy treatment OTC. Generally, when the condition is long-term (such as perennial rhinitis), treatments available OTC may be prescribed in primary care. See the section on Prescribing information for further information.

Advise on or prescribe first-line treatment, considering patient preference, age, severity of symptoms, persistence of symptoms and the following facts:

First-line treatment options are intranasal corticosteroids and antihistamines (intranasal or non-sedating oral antihistamines), either alone or in combination.
Intranasal corticosteroids are the most effective treatment for allergic rhinitis, but patients may prefer oral medication. They may take several hours to several days to become effective. Options include intranasal mometasone furoate, fluticasone furoate, or fluticasone propionate, which have minimal systemic absorption.
Intranasal antihistamines (such as azelastine) have the fastest onset of action (within minutes) but are less effective than intranasal corticosteroids.
The combination of an intranasal corticosteroid and an oral antihistamine is no more effective than the intranasal corticosteroid on its own. However, the combination of an intranasal corticosteroid with an intranasal antihistamine is more effective than an intranasal corticosteroid on its own.
Consider regularly prescribed intranasal corticosteroids for people with moderate to severe, persistent allergic rhinitis.

If allergic rhinitis is mild, intermittent, or both:

In children, suggest an antihistamine (intranasal or oral non-sedating antihistamine).
In adolescents and adults, any first-line treatment may be offered. (Intranasal or oral non-sedating antihistamine, or intranasal corticosteroid, or a combination of nasal corticosteroid with oral or intranasal antihistamine.)

If allergic rhinitis is moderate to severe (i.e. impacting on quality of life, sleep, or daily living activities) or persistent:

Suggest an intranasal corticosteroid or the combination of an intranasal corticosteroid with an intranasal antihistamine.
- Advise the person that the onset of action for intranasal corticosteroids is 6–8 hours after the first dose, but the maximal effect may not be seen until after two weeks.
- Nasal drops may be preferred if there is severe nasal obstruction.
- Advise the person not to increase beyond the prescribed dose as there is no evidence of additional benefit, and do not switch to an alternative preparation as they all have comparable efficacy.
If symptoms are intermittent and there is no ongoing allergen exposure, step down treatment and stop, but if symptoms are persistent or there is ongoing exposure then continue treatment or step up if not controlled.
- If drug treatment provides adequate symptom control, advise the person to continue treatment until they are no longer likely to be exposed to the suspected allergen. For people allergic to:
  - House dust mite and/or pets in the home — symptoms are usually present throughout the year, requiring ongoing treatment.
  - Tree pollens — treatment is usually required from early to late spring.
  - Grass pollens — treatment is usually required from late spring to early summer.
  - Weed pollens — treatment is usually required from early spring to late autumn.
    - If there are recurrent episodes of symptoms controlled by intranasal corticosteroids, advise the person to restart treatment two weeks before re-exposure to causative allergens.
    - If the time of re-exposure is uncertain, such as the start of the pollination season, advise the person to start treatment several weeks before the most likely time of re-exposure.
- Advise the person to be reviewed after 2–4 weeks if symptoms persist after initial treatment, as management may need to be stepped up. See the section on Treatment failure and referral for more information.

If there are additional eye symptoms:

Advise or prescribe antihistamine eye drops or chromone eye drops (sodium cromoglycate, nedocromil).

Basis for recommendation

These recommendations are largely based on the 2020 Next generation Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines for allergic rhinitis based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and real-world evidence [Bousquet, 2020b] and expert opinion in the British Society of Allergy and Clinical Immunology guideline BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis [Scadding, 2017]. In addition, this information is supported by a primary care expert consensus statement An algorithm recommendation for the pharmacological management of allergic rhinitis in the UK [Lipworth, 2017], treatment algorithms from the European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) [Euforea, 2021a; Euforea, 2021b], the International consensus statement on allergy and rhinology: Allergic rhinitis - 2023 [Wise, 2023], and expert opinion in review articles on allergic rhinitis, Allergic rhinitis in children [Barr, 2014], Allergic rhinitis [Bousquet, 2020a], and Allergic rhinitis: a common problem, not to be sneezed at [Stonham, 2022].

First line treatment

The recommendations on considering which medication to choose come from the information used to support the 2020 Next generation ARIA guidelines for allergic rhinitis based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and real-world evidence [Bousquet, 2020b].
The recommendations on first-line management are also based on these 2020 ARIA guidelines [Bousquet, 2020b] as well as treatment algorithms from the European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) [Euforea, 2021a; Euforea, 2021b], which give specific advice for management in the paediatric population. These make minor changes from the 2017 British Society of Allergy and Clinical Immunology guideline BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis [Scadding, 2017] and build on the previous ARIA publications.
Information from a review of the literature in a 2023 international consensus statement suggests the use of intranasal corticosteroids may have an impact on growth in children, hence this use in children is restricted to those with more severe or persisting symptoms [Wise, 2023]. This statement advises that the lowest effective dose should be used, and growth should be monitored. The information that intranasal mometasone furoate, fluticasone furoate, or fluticasone propionate have little systemic absorption is based on the 2017 BSACI guideline which states these should be favoured for use in children [Scadding, 2017]. This is further supported by information on the use of intranasal corticosteroids in the British National Formulary [BNF, 2023; BNFC, 2023] and a 2021 narrative review which reviewed the evidence found these second-generation nasal corticosteroids and found these second-generation products to be optimal in terms of systemic exposure as well as topical potency [Daley-Yates, 2021].
Information about the prescribing policy for over-the-counter medication is based on the experience of the CKS reviewers and guidance from NHS England [NHS England, 2018].
The current ARIA and Euforea algorithms above are based on using a visual analogue scale (VAS). The recommendations for mild here are taken from a VAS score of less than 5, and those for moderate to severe are based on those for a VAS score of 5 or more.

Advice on durations of drug treatment

The information on the timings of likely exposure to causative allergens is extrapolated from information in the 2008 revision of the ARIA international guideline [Bousquet, 2008]. Subsequent updates were targeted and did not include this information.
The recommendation to start intranasal corticosteroids two weeks prior to a known allergen season is based on the fact that the maximal effect of intranasal corticosteroids may not be seen until two weeks after starting treatment [Scadding, 2017].

Arranging review if symptoms persist

The recommendation to arrange review if symptoms persist after 2–4 weeks is based on an expert consensus statement, which considers a two-week trial appropriate to assess initial response to antihistamines, and a four-week trial appropriate for intranasal corticosteroids [Lipworth, 2017].

How should I manage treatment failure?

If a person has uncontrolled symptoms following initial self-management strategies and drug treatment:

Consider causes for treatment failure.
- Check compliance with self-management strategies, if appropriate.
- Check compliance with initial drug treatments and/or the correct technique when using intranasal sprays or drops.
- An alternative diagnosis or non-allergic cause for symptoms.
Consider stepping up treatment if a person has refractory symptoms while using a regular intranasal corticosteroid preparation.
- If sudden or severe nasal congestion is a problem, consider adding in a short-term intranasal decongestant such as xylometazoline for up to 5–7 days, depending on the person's age and preparation used.
  - See the section on Intranasal decongestants in Prescribing information for more information.
- If there is persistent watery rhinorrhoea despite a combined use of an intranasal corticosteroid and oral antihistamine, add in an intranasal anticholinergic such as ipratropium bromide in adults or young people aged 12 or older.
  - See the section on Intranasal anticholinergics in Prescribing information for more information.
- If there is persistent nasal itching and sneezing, options are to add in an oral antihistamine to be used regularly rather than 'as needed', or to prescribe a combination preparation containing an intranasal antihistamine and an intranasal corticosteroid such as Dymista^® (azelastine and fluticasone propionate) or Ryaltris^® (olopatadine and mometasone) spray, if monotherapy with either an antihistamine or intranasal corticosteroid is ineffective.
  - See the sections on Oral antihistamines and Combined intranasal corticosteroid and antihistamine sprays in Prescribing information for more information.
  - Note: combined use of an intranasal and oral antihistamine is not recommended.
- If the person has ongoing symptoms and a history of asthma, consider adding a leukotriene receptor antagonist such as montelukast to an oral or intranasal antihistamine.
  - See the section on Oral leukotriene receptor antagonists in Prescribing information for more information.
- If an adult has severe, uncontrolled symptoms that are significantly affecting quality of life, consider prescribing a short course of oral corticosteroids to provide rapid symptom relief, such as:
  - For adults — prednisolone 0.5 mg/kg in the morning for 5–10 days.
    - See the CKS topic on Corticosteroids - oral for more prescribing information.
  - For children — seek advice from a specialist if considering prescribing an oral corticosteroid in this situation.
If drug treatment provides adequate symptom control, advise the person to continue treatment until they are no longer likely to be exposed to the suspected allergen. For people allergic to:
- House dust mites and/or pets in the home — symptoms are usually present throughout the year, requiring ongoing treatment.
- Tree pollens — treatment is usually required from early to late spring.
- Grass pollens — treatment is usually required from late spring to early summer.
- Weed pollens — treatment is usually required from early spring to late autumn.
  - If there are recurrent episodes of symptoms controlled by intranasal corticosteroids, advise the person to restart treatment two weeks before re-exposure to causative allergens.
  - If the time of re-exposure is uncertain, such as the start of the pollination season, advise the person to start treatment several weeks before the most likely time of re-exposure.
Consider arranging referral for specialist assessment and management to an allergy or ear, nose, and throat (ENT) specialist if:
- There are red flag features such as unilateral symptoms, blood-stained nasal discharge, recurrent epistaxis, or nasal pain — arrange an urgent two-week wait referral to ENT.
- There is predominant nasal obstruction and/or a structural abnormality such as deviated nasal septum which makes intranasal drug treatment difficult — arrange referral to ENT.
- There are persistent symptoms despite optimal management in primary care — consider referral to an allergy specialist for allergy testing and possible immunotherapy treatment, depending on local referral pathways and availability.
- Allergen avoidance techniques such as house dust mite or animal dander avoidance are being considered — skin prick allergy testing to confirm the responsible allergen may be needed.
- The person would like to consider specialist immunotherapy treatment rather than take medication long term.
- The diagnosis is uncertain — consider referral to an allergy or ENT specialist, depending on clinical judgement.

Basis for recommendation

These recommendations are largely based on the Allergic Rhinitis and its Impact on Asthma (ARIA) international guidelines 2008 publication [Bousquet, 2008], and the 2020 targeted update Next-generation ARIA guidelines for allergic rhinitis based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and real-world evidence [Bousquet, 2020b], expert opinion in the British Society of Allergy and Clinical Immunology guideline BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis [Scadding, 2017], a primary care expert consensus statement An algorithm recommendation for the pharmacological management of allergic rhinitis in the UK [Lipworth, 2017], the International consensus statement on allergy and rhinology: Allergic rhinitis - 2023 [Wise, 2023], 2021 treatment algorithms from the European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) [Euforea, 2021a; Euforea, 2021b], and expert opinion in review articles on allergic rhinitis, Allergic rhinitis in children [Barr, 2014], Allergic rhinitis [Bousquet, 2020a], and Allergic rhinitis: a common problem, not to be sneezed at! [Stonham, 2022].

Adding in an intranasal anticholinergic

Ipratropium is not licensed for this indication for children under the age of 12, nor is it recommended in guidelines for children [Euforea, 2021b; Scadding, 2021; BNF, 2023].

Prescribing oral corticosteroids for severe refractory symptoms

The 2020 Next-generation ARIA guidelines for allergic rhinitis based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and real-world evidence recommends a short 3–7 day course as an add-on option when a step-up from the combination of an intranasal corticosteroid and intranasal antihistamine is required [Bousquet, 2020b]. The 2021 European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) pocket guide for allergic rhinitis includes a short course of oral corticosteroid as an option for uncontrolled symptoms [Euforea, 2021a] without being specific about the dose or length of course.
The BSACI guideline notes there is no consensus in the literature on the optimal dose and duration of oral corticosteroid treatment, but suggests a dose for adults of 0.5 mg/kg in the morning, for 5–10 days. It also advises the person to continue using an intranasal corticosteroid preparation, to allow optimal intranasal cavity drug penetration [Scadding, 2017]. This guideline suggests that for children a course of 3–7 days of an oral corticosteroid may be required in severe cases but does not give any recommendation as to dose.
The basis for not recommending this option in primary care for children is based on the EUFOREA management algorithms in the pocket guides, which do not advise this as an option for children, and the fact that the BSACI guideline only refers to an adult-specific suggested dose regimen [Scadding, 2017; Euforea, 2021a; Euforea, 2021b]. The British National Formulary and the SPC for prednisolone do not include allergic rhinitis as a licensed indication for children and there is no suggested dose regimen for this scenario [BNF, 2023; BNFC, 2023; EMC, 2023a]. CKS concluded it would be prudent to seek advice from a specialist before prescribing a steroid to a child in this situation.

Advice on durations of drug treatment

The information on the timings of likely exposure to causative allergens is extrapolated from information in the 2008 ARIA international guideline [Bousquet, 2008]. Subsequent updates have been targeted and did not include this information.
The recommendation to start intranasal corticosteroids 2 weeks prior to a known allergen season is based on the fact that the maximal effect of intranasal corticosteroids may not be seen until 2 weeks after starting treatment [Scadding, 2017]. The British National Formulary (BNF) also advises that treatment for seasonal allergic rhinitis should begin 2–3weeks before the season commences and/or exposure to the allergen [BNF, 2023].

Immunotherapy treatment

Specialist immunotherapy may be appropriate for people with symptoms of allergen exposure, objective confirmation of IgE sensitivity, and persistent symptoms predominantly due to one allergen such as grass pollen or house dust mite. Treatment may be by subcutaneous injection or sublingual, and involves exposing the person to increasing amounts of an allergen to induce clinical and immunological tolerance.
- Subcutaneous therapy may involve weekly initial dosing regimens followed by 4–6 weekly maintenance injections, usually for 3 years. Pre-seasonal immunotherapy may be effective for pollen allergy.
- Sublingual immunotherapy may be an alternative for the treatment of allergic rhinitis due to one or more species of grass pollen and house dust mites. If tolerated, subsequent doses may be self-administered daily at home for, usually, 3 years.
- Adverse effects are generally short-lived: subcutaneous immunotherapy may cause itching, redness, and swelling at the injection site; sublingual immunotherapy may cause oropharyngeal itching and localized swelling which typically settles with repeated dosing.
- Immunotherapy is the only treatment that can modify disease progression, with long-term remission possible following the end of treatment. Subcutaneous immunotherapy in children with seasonal rhinitis may reduce the risk of progression to asthma, and may prevent the development of new sensitizations.

[Brozek et al, 2010; Barr, 2014; Lipworth, 2017; Scadding, 2017; BMJ Best Practice, 2023; Wise, 2023]

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://medicines.org.uk/emc), or the British National Formulary (BNF).

Intranasal corticosteroids

This section includes general information on prescribing intranasal corticosteroids, as well as specific dose information for mometasone, fluticasone propionate and fluticasone furoate as these are the ones with the lowest systemic absorption as advised by current guidance and evidence [Scadding, 2017; Daley-Yates, 2021; BNF, 2023]. For more information on prescribing these and other intranasal corticosteroids, see the CKS topic Corticosteroids - topical (skin), nose and eyes, and also the British National Formulary (BNF) and the Electronic Medicines Compendium (EMC).

Dose

Mometasone intranasal spray

Children 3-11 years — 50 micrograms once daily, dose to be sprayed into each nostril.
Children from 12 years and adults — 100 micrograms once daily, dose to be sprayed into each nostril. If necessary increase up to 200 micrograms once daily, the dose to be sprayed into each nostril, reducing the dose when control has been achieved.
One spray is equal to 50 micrograms.

Fluticasone propionate nasal spray

Children 4-11 years — 50 micrograms once daily, to be administered to each nostril, preferably in the morning, increased if necessary to 50 micrograms twice daily.
Children from 12 years and adults — 100 micrograms once daily to be administered into each nostril preferably in the morning, increased if necessary to 100 micrograms twice daily. Once symptoms are controlled, reduce the dose to 50 micrograms to each nostril once a day.
One spray is equal to 50 micrograms.

Fluticasone furoate intranasal spray (Avamys^®)

Children 6-11 years — 27.5 micrograms once daily, dose to be sprayed into each nostril. Increase, if necessary, to 55 micrograms once daily, dose to be sprayed into each nostril. Reduce the dose when control is achieved and use the minimum effective dose.
Children from 12 years and adults — 55 micrograms once daily, dose to be sprayed into each nostril. Reduce to 27.5 micrograms once daily to be sprayed into each nostril when control has been achieved and use the minimum effective dose.
One spray is equal to 27.5 micrograms.

For dosing regimens for other intranasal corticosteroids, see the British National Formulary (BNF) or Electronic Medicines Compendium (EMC).

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Allergic rhinitis: Summary

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Goals

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Background information

What is it?

What causes it?

What are the risk factors?

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What is the prognosis?

Diagnosis of allergic rhinitis

When should I suspect allergic rhinitis?

Basis for recommendation

How should I assess a person with suspected allergic rhinitis?

Basis for recommendation

Investigations

Basis for recommendation

What else might it be?

Basis for recommendation

Management

Scenario: Management

What self-management strategies should I advise?

Basis for recommendation

Advice on pollen allergen avoidance

Advice on animal dander allergen avoidance

What initial drug treatments should I recommend?

Basis for recommendation

First line treatment

Advice on durations of drug treatment

Arranging review if symptoms persist

How should I manage treatment failure?

Basis for recommendation

Adding in an intranasal anticholinergic

Fluticasone furoate intranasal spray (Avamys^®)