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Allergic rhinitis: Pharmacy First treatment summary

Hay fever in children aged 3 to 11: a summary of the Pharmacy First seasonal allergic rhinitis pathway, from red flags and prescribing criteria to nasal sprays, self-care and review

Ross Ferguson, 29 Oct 202617 Min

In Pharmacy First

Signs and symptoms

Typical features of seasonal allergic rhinitis
●	Symptoms on both sides, at the same time each year (pollen season)^1,3
●	Sneezing, nasal itching, clear watery discharge or nasal blockage^1,3
●	Itchy, red or watery eyes may also be present^1,3
If these features are absent: allergic rhinitis less likely
●	Consider another diagnosis, such as perennial allergic rhinitis, a viral illness, sinusitis, enlarged adenoids, a foreign body, or symptoms linked to regular decongestant nasal spray use^1,2
●	Give self-care advice where suitable; otherwise refer to general practice¹

Referral

Immediate
●	Life-threatening emergency: A&E or 999¹
Urgent (same-day GP, out-of-hours service or A&E, depending on circumstances)
●	High fever, severe facial pain or facial swelling^1,2
●	Marked, one-sided or painful eye swelling; double or reduced vision, severe eye pain or photophobia^1,2
●	Acute wheeze or breathlessness^1,2
●	Persistent one-sided blockage or discharge, blood-stained discharge, suspected mass or foreign body^1,2
General practice
●	Recurrent or heavy nosebleeds, or recent nasal injury or surgery. Community pharmacies cannot refer directly to ENT^1,2
●	Predominant nasal obstruction without rhinorrhoea, itch or sneezing²
●	Perennial rhinitis²
●	Diagnosis uncertain, or a structural nasal abnormality (for example, a deviated septum)²
●	Rhinitis medicamentosa (rebound congestion from regular decongestant nasal spray use)²
●	Features indicative of acute bacterial sinusitis, or suspected bilateral nasal polyps²
●	Two prescriptions already issued in the current pollen season: ongoing management passes to general practice²
●	Not improved despite regular use and correct technique, after the second prescription¹
Treat AND arrange a review
●	Asthma not well controlled: arrange a general practice or asthma review. Rhinitis treatment may continue if otherwise suitable^1,2

Treatment options

Pathway: prescribe only if ALL of the following apply
●	Still symptomatic despite an adequate trial of a non-sedating antihistamine, or an antihistamine is unsuitable or not tolerated¹
●	Symptoms materially affect sleep or usual activities¹
●	The child and parent or carer can use the nasal spray correctly¹
●	If a non-sedating antihistamine has not been tried: advise one as self-care¹
Pathway: treatment
●	Offer an age-licensed intranasal corticosteroid plus self-care¹
Intranasal corticosteroid doses for children
●	Mometasone, ages 3–11: 50 micrograms once daily, sprayed into each nostril³
●	Fluticasone propionate, ages 4–11: 50 micrograms once daily into each nostril, preferably in the morning. Increase if necessary to 50 micrograms twice daily³
●	Fluticasone furoate (Avamys), ages 6–11: 27.5 micrograms once daily into each nostril. Increase if necessary to 55 micrograms once daily, then reduce to the minimum effective dose³
●	Check the age licence of the product chosen^1,3
Cautions
●	Do not prescribe with recent nasal surgery, untreated nasal infection or pulmonary tuberculosis. Caution with immunosuppression³
●	Use the lowest effective dose. Monitor height with prolonged use, and consider referral to a paediatrician if growth slows³
●	Common adverse effects: altered smell or taste, nosebleeds, nasal ulceration, headache and throat irritation³

Self-care and advice

Using the nasal spray
●	Demonstrate nasal-spray technique and regular daily use¹
●	Explain that full benefit may take up to 4 weeks. NICE CKS: onset is 6–8 hours after the first dose, with the maximal effect after about 2 weeks^1,3
●	Do not increase beyond the prescribed dose: there is no evidence of additional benefit³
Avoiding pollen
●	Avoid walking in grassy, open spaces, particularly in the early morning, early evening and during mowing, when the pollen count is high³
●	Avoid drying washing outdoors, and keep windows shut in cars and buildings, when the pollen count is high³
●	Shower or wash hair after high pollen exposure³
●	Consider wraparound sunglasses or nasal barriers (balms or creams rubbed on the nose) when the pollen count is high³
●	Consider saline nasal irrigation, available over the counter³
Patient information
●	NHS website: hay fever, and the Asthma + Lung UK pollen calendar for forecasts^1,4
Safety-netting advice for patient
●	Seek urgent help for marked, one-sided or painful eye swelling, visual change, facial swelling or breathing difficulty¹
●	Return for review if not improving with regular use, or if a further prescription is needed¹

Follow up

Pharmacist review
●	Check for new red flags or one-sided symptoms¹
●	Check regular use, spray technique, tolerability and response¹
●	For nosebleeds, check technique and nasal inflammation. Refer if persistent, heavy or recurrent¹
●	If improved, consider a second prescription for the current pollen season, where appropriate^1,2
●	If not improved, consider a second prescription, but for an alternative spray²
If treatment has not worked (2 prescriptions issued)
●	Not improved despite regular use and correct technique: refer to general practice¹

References
1	NHS England. Pharmacy First: seasonal allergic rhinitis prescribing pathway (children aged 3 to 11 years). Final draft v0.10.
2	NHS England. NHS Community Pharmacy Clinical Prescribing Guidance, final draft. Section B5, Seasonal allergic rhinitis in children aged 3 to 11 years (pages 39–40).
3	NICE Clinical Knowledge Summaries. Allergic rhinitis. Last revised January 2024. Management: scenario, management; prescribing information.
4	NHS website. Hay fever (patient information).

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